Audit

Medical Record Details

Medical Record Number

CRITERIA - PAPER BASED MEDICAL RECORD

Identification completed on ALL Consultation Report pages (Minimum: First name, Last name, DOB) Patient Label is ideal

Correspondence filed are for the correct patient

Results filed are for the correct patient

Patient labels are correct and current

Medical record file / cover is in good working order

Documents are in reverse chronological order (most recent on top)

Documents are separated into appropriately tab eg. Results tab

CRITERIA - ELECTRONIC MEDICAL RECORD

Pathology is labelled / filed correctly

Diagnostic Imaging is labelled / filed correctly

Electronic letters are for the correct patient

Scanned documents are for the correct patient

Electronic Letters - FORWARDED

Electronic Letters - SENT BACK

Electronic Letters - DISTRIBUTED

CRITERIA - HOST ACCESS PATIENT REGISTRATION SCREEN

General Practitioner is recorded on Patient Registration Screen

Marital status is recorded on Patient Registration Screen ( if known)

Title is recorded on Patient Registration Screen

Next Of Kin is recorded

Copy To Doctors are on Referral Screen

If Deceased, record is marked "deceased" on Patient Registration Screen

If Deceased, record is marked "Estate of" on Patient Registration Screen

If Deceased, Date of Death is recorded

Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.