Medical Record Audit

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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

  Yes

  No

  N/A

• Correspondence filed are for the correct patient

  Yes

  No

  N/A

• Results filed are for the correct patient

  Yes

  No

  N/A

• Patient labels are correct and current

  Yes

  No

  N/A

• Medical record file / cover is in good working order

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Documents are separated into appropriately tab eg. Results tab

  Yes

  No

  N/A

CRITERIA - ELECTRONIC MEDICAL RECORD

• Pathology is labelled / filed correctly

  Yes

  No

  N/A

• Diagnostic Imaging is labelled / filed correctly

  Yes

  No

  N/A

• Electronic letters are for the correct patient

  Yes

  No

  N/A

• Scanned documents are for the correct patient<br>

  Yes

  No

  N/A

• Electronic Letters - FORWARDED

  Yes

  No

  N/A

• Electronic Letters - SENT BACK

  Yes

  No

  N/A

• Electronic Letters - DISTRIBUTED

  Yes

  No

  N/A

CRITERIA - HOST ACCESS PATIENT REGISTRATION SCREEN

• General Practitioner is recorded on Patient Registration Screen

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Title is recorded on Patient Registration Screen

  Yes

  No

  N/A

• Next Of Kin is recorded

  Yes

  No

  N/A

• Copy To Doctors are on Referral Screen

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• If Deceased, Date of Death is recorded

  Yes

  No

  N/A

• Signature

  Sign