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Medical Audit Checklist

Patient Record System

All clinical information is recorded electronically, password protected and reliably backed up.

Patient records are electronic, secure and traceable.

Clinical notes are dated and reliably identify the author.

Basic demographic information is sufficient to allow for patient identification and to meet national enrolment requirements.

Medical Record Review

The record is appropriate, contemporaneous and sources are identified.

Notes are completed as soon as possible after contact, and any delay is identifiable.

Information is recorded objectively and does not contain inappropriate, judgmental comment.

When information is provided other than by the patient, the source is identified.

Clinical notes can be understood by someone not working regularly at the practice.

The notes are logical, intelligible and sequential.

The use of keywords or templates does not compromise the validity of the notes.

Important background issues, warnings and alerts are displayed for all records.

Past medical history is available.

Significant social history is included.

The PMS is used to effectively display important warnings, and alerts.

Allergies or the absence of known allergies is recorded for each patient.

Specific patient needs and instructions are recorded and are available in easily accessible form at the clinically relevant point.

Patient needs recorded include any directives by patient, disabilities, drug dependencies, end of life and special needs (eg communication, mental health issues).

The recorded history is relevant and sufficient for both safe management and evidential purposes.

The reason(s) for the encounter recorded or apparent from the notes.

The record includes date, place of consultation (if different from usual) and mode of contact if not face to face.

The record includes all findings essential to diagnosis and management.

Sufficient positive and negative history and examination findings are present to justify management decisions.

Objective measurements (BP, pulse, temp., respiratory rate, PaO2 etc) are recorded, where relevant.

The working diagnosis/differential or problem being managed is apparent and consistent with supporting information.

The diagnosis (and any differential) and level of certainty is clear from the notes.

The patient management plan is clear and identifies and addresses uncertainty and conjecture.

The plan for care can be identified from the record.

Important assumptions and remaining uncertainties in diagnosis and management are noted.

The record identifies information given to the patient, including risks and benefits of treatments and, where relevant,
consent.

Notification of test results and clinical findings is recorded.

The record supports adequate consenting processes.

All important clinical decisions and interventions are recorded.

Treatment plans, including interventions, contingency plans, safety netting and follow-up arrangements are recorded as necessary.

Clinical management decisions made outside consultations (eg telephone calls) and off-site contacts (home visit, aged care facilities etc) are recorded.

The record identifies all medication treatment provided, including the type, dosage and total amount of any
medications prescribed.

There is a record of all prescriptions issued, including drug name, administration instructions and quantities ordered.

Medications initiated or changed outside the practice are reconciled with the PMS.

Current and long-term medications are differentiated and the status is clear.

Where long-term medications are changed, reasons for alteration or discontinuation are clear.

The record identifies all investigations requested and tracks high-risk tests.

All requests for tests and investigations are recorded.

High-risk tests (eg histology, cervical smears) are tracked for completion.

The record supports effective and timely referral for treatment or transfer of care.

The record shows that referrals are completed within a reasonable time frame.

Copies of referral letters to and from the practice, certifications, referrals and responses, discharge summaries and test results are included in the patient PMS record or accessibly filed.

Referrals include urgency, reason/expectation of referral, relevant findings, classifications, warnings and current treatment.

The transfer of responsibility for care can be verified from the records.

Follow-up of test results is clearly documented and actions recorded.

Follow-up actions on test results and referrals are recorded.

Screening history and results (or declined screening) are recorded.

Screening history and results (including declines) are evident for routine screening areas (eg cervical smears, mammograms, cardiovascular risk assessment, diabetes screening).

Screening recall status can be easily tracked.

There is evidence of patient risk assessment and opportunistic screening for high-risk conditions.

Immunisation history and status is recorded.

There is evidence that recommended immunizations are provided in accordance with the national schedule.

Records show advice given and immunization status for non-scheduled immunizations.

There is a systematic record of individual risk factors.

Diseases are classified for chronic conditions, including all conditions for which the patient is on long-term treatment.

Family history for major risk factors, such as diabetes, early CVD, bowel and breast cancer etc.

Current employment (where relevant) and any history of at-risk occupations.

Blood pressure monitoring as clinically indicated.

Baseline weight/BMI and monitoring as clinically indicated.

Smoking status and history and cessation support offered, where relevant.

Alcohol and drug usage.

Regular review of chronic conditions as per current best practice (eg INR, diabetes, CVR).

Completion

Additional Recommendations

Reviewer Name & Signature
Multidisciplinary Team
Name, Department & Signature

Medical Audit Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 3

Use this digital medical audit checklist to easily determine if the current clinical documentation in medical records are compliant, partly compliant or non-compliant to national regulations or industry standards.

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Medical Audit Checklist

Patient Record System

All clinical information is recorded electronically, password protected and reliably backed up.

Patient records are electronic, secure and traceable.

Clinical notes are dated and reliably identify the author.

Basic demographic information is sufficient to allow for patient identification and to meet national enrolment requirements.

Medical Record Review

The record is appropriate, contemporaneous and sources are identified.

Notes are completed as soon as possible after contact, and any delay is identifiable.

Information is recorded objectively and does not contain inappropriate, judgmental comment.

When information is provided other than by the patient, the source is identified.

Clinical notes can be understood by someone not working regularly at the practice.

The notes are logical, intelligible and sequential.

The use of keywords or templates does not compromise the validity of the notes.

Important background issues, warnings and alerts are displayed for all records.

Past medical history is available.

Significant social history is included.

The PMS is used to effectively display important warnings, and alerts.

Allergies or the absence of known allergies is recorded for each patient.

Specific patient needs and instructions are recorded and are available in easily accessible form at the clinically relevant point.

Patient needs recorded include any directives by patient, disabilities, drug dependencies, end of life and special needs (eg communication, mental health issues).

The recorded history is relevant and sufficient for both safe management and evidential purposes.

The reason(s) for the encounter recorded or apparent from the notes.

The record includes date, place of consultation (if different from usual) and mode of contact if not face to face.

The record includes all findings essential to diagnosis and management.

Sufficient positive and negative history and examination findings are present to justify management decisions.

Objective measurements (BP, pulse, temp., respiratory rate, PaO2 etc) are recorded, where relevant.

The working diagnosis/differential or problem being managed is apparent and consistent with supporting information.

The diagnosis (and any differential) and level of certainty is clear from the notes.

The patient management plan is clear and identifies and addresses uncertainty and conjecture.

The plan for care can be identified from the record.

Important assumptions and remaining uncertainties in diagnosis and management are noted.

The record identifies information given to the patient, including risks and benefits of treatments and, where relevant,
consent.

Notification of test results and clinical findings is recorded.

The record supports adequate consenting processes.

All important clinical decisions and interventions are recorded.

Treatment plans, including interventions, contingency plans, safety netting and follow-up arrangements are recorded as necessary.

Clinical management decisions made outside consultations (eg telephone calls) and off-site contacts (home visit, aged care facilities etc) are recorded.

The record identifies all medication treatment provided, including the type, dosage and total amount of any
medications prescribed.

There is a record of all prescriptions issued, including drug name, administration instructions and quantities ordered.

Medications initiated or changed outside the practice are reconciled with the PMS.

Current and long-term medications are differentiated and the status is clear.

Where long-term medications are changed, reasons for alteration or discontinuation are clear.

The record identifies all investigations requested and tracks high-risk tests.

All requests for tests and investigations are recorded.

High-risk tests (eg histology, cervical smears) are tracked for completion.

The record supports effective and timely referral for treatment or transfer of care.

The record shows that referrals are completed within a reasonable time frame.

Copies of referral letters to and from the practice, certifications, referrals and responses, discharge summaries and test results are included in the patient PMS record or accessibly filed.

Referrals include urgency, reason/expectation of referral, relevant findings, classifications, warnings and current treatment.

The transfer of responsibility for care can be verified from the records.

Follow-up of test results is clearly documented and actions recorded.

Follow-up actions on test results and referrals are recorded.

Screening history and results (or declined screening) are recorded.

Screening history and results (including declines) are evident for routine screening areas (eg cervical smears, mammograms, cardiovascular risk assessment, diabetes screening).

Screening recall status can be easily tracked.

There is evidence of patient risk assessment and opportunistic screening for high-risk conditions.

Immunisation history and status is recorded.

There is evidence that recommended immunizations are provided in accordance with the national schedule.

Records show advice given and immunization status for non-scheduled immunizations.

There is a systematic record of individual risk factors.

Diseases are classified for chronic conditions, including all conditions for which the patient is on long-term treatment.

Family history for major risk factors, such as diabetes, early CVD, bowel and breast cancer etc.

Current employment (where relevant) and any history of at-risk occupations.

Blood pressure monitoring as clinically indicated.

Baseline weight/BMI and monitoring as clinically indicated.

Smoking status and history and cessation support offered, where relevant.

Alcohol and drug usage.

Regular review of chronic conditions as per current best practice (eg INR, diabetes, CVR).

Completion

Additional Recommendations

Reviewer Name & Signature
Multidisciplinary Team
Name, Department & Signature