Looking Over Your Shoulder in Healthcare: Chart Audits

Part 2

Carolyn Buppert, NP, JD

Disclosures

December 08, 2011

In This Article

Audit Yourself Before Someone Else Does

Clinicians are advised to keep in mind the different readers of medical record documentation, whether it's an auditor for a payer, an attorney or expert in a malpractice case, a licensing board reviewer, an accreditation visitor, or another clinician. At the minimum, be certain that the note is legible, regardless of who will be reading it. Ideally, read over the note yourself to determine whether it meets the requirements for the CPT code you selected, whether it documents that you followed up as needed, and whether your documentation is going to help -- or at least not hinder -- the facility during an accreditation visit.

Managers and administrators are advised to enlist a qualified individual periodically to audit the records written by the clinicians you manage, so that you won't be in the position of having to defend the documentation when audited by an outsider. Part 3 of this series will describe a plan for internal auditing and training to improve documentation.

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