Chart Audit

Chart Audits: The how’s and why’sBy:Victoria Kaprielian, MDBarbara Gregory, MPHDev Sangvai, MDBy Victoria Kaprielian, MDAssociate Clinical ProfessorBarbara Gregory, MPHQuality AnalystDev Sangvai, MDDepartment of Community and Family MedicineDuke University Medical CenterCopyright 20031OverviewThis module will cover: • Definition of audit• Purposes of an audit• How to conduct an auditObjectives: Upon completion of this module, the learner will be able to:1. State the definition and purposes of a medical records audit.2. List the necessary steps in designing and conducting a chart audit for Quality Improvement.3. Design a chart audit for a quality measure, including:- topic selection, - identification of a clearly defined performance measure, - ion of target population and sample size- design of data collection methods and tools, and - identification of appropriate benchmarks.4. Perform a chart audit and report results in a format useable for quality improvement efforts.2DefinitionA chart audit is an examination of medical records, electronic and/or hard copy, to measure some component of performanceA chart audit is an examination of medical records, to determinewhat is done, and see if it can be done better. There are countless numbers of performance components that can be measured in a chart audit. Examples include:- adherence to clinical protocols, - patient adherence with medication regimens, - ...