Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

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<br>

  • 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

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