Medical record documentation audit tool for hospitals

After conducting numerous audits of medical record documentation for hospitals, Carolyn Buppert has developed a program whereby providers can conduct their own audits, provide training targeted to audit results and then re-audit and track improvement. The package consists of 75 audit questions, the rationale behind each question, a data collection tool, plan for analysis of audit data, training modules tailored to audit results, re-evaluation questions and a plan for continued evaluation and training.

The objectives of the program are:

  • Identify the entities looking over the shoulder of the provider
  • Identify problem areas at this hospital
  • Analyze the source of the problem
  • Train for improvement
  • Measure improvement
  • Continue evaluation/analysis/improvement cycle

The benefits are:

For executives:

  • Prepare for various outside audits — JCAHO and payers
  • Avoid sentinel events
  • Avoid payment denials
  • Undertake an unbiased, nonjudgmental evaluation of strengths and weaknesses

For supervisors:

  • Take a proactive approach to finding and correcting problem areas on the unit
  • Outside evaluator removes onus from supervisor (if audit is conducted by my office)
  • Little or no additional work for the supervisor (if audit is conducted by my office)

For the registered nurse:

  • Continuing education
  • Receive feedback on your work from an outside observer
  • Evaluations not tied to discipline or advancement in the facility
  • Improve charting without adding more hours of writing time
  • Opportunity to provide input to analysis of facility operations

For the nurse practitioner, physician assistant or physician:

  • Improve productivity by increasing billing opportunity with same or less work
  • Decrease likelihood of litigation for malpractice
  • If lawsuit is filed, increase likelihood of a successful defense

Why concentrate of medical record documentation?

Medical record documentation is the basis on which clinical care is judged. But often, very little analysis of documentation is conducted unless an unfortunate incident occurs. When an incident occurs, records are scrutinized critically by outside entities. One professional liability insurer which audited random samples of medical records for deficiencies in charting found that allergies were not noted on 40% of charts, prescriptions and refills were poorly tracked on 66% of charts, dictation was not timely in 40% of charts and informed consent was not noted in 27% of charts. While these deficiencies in documentation are not likely to be the basis of malpractice lawsuits, these types of errors or omissions hamper the defense in a malpractice lawsuit. A plaintiff’s attorney may seize upon deficiencies in documentation to demonstrate that the clinician being sued is sloppy, negligent, or incompetent.

Documentation affects finances as well as legal liability. Medicare reports that it denies payment when the medical record documentation is insufficient to support a claim for hospitalization or a physician service. When a payer audits, sloppy documentation may lead not only to denial of payment, but inspires auditors to look more closely at the facility than if the documentation is clear and appropriate.

The medical record must serve many masters — other clinicians, payers, accreditation visitors, and if an incident occurs, attorneys, experts, judges, juries and licensing boards. Therefore, I urge executives and managers to conduct internal audits, so that problem areas can be identified prior to a mishap or a failure and so that staff can be educated about the components of excellent documentation and the reasons why it is needed. The Law Office of Carolyn Buppert has developed a set of tools for use by hospitals to audit and use the data obtained to improve quality of care, reduce risk of patient injury, and improve performance on payer audits and accreditation visits. For those who aren’t do-it-yourselfers, the office offers on-site auditing, evaluating and training services.

For hospitals:
Hospitals are audited by Medicare, Medicaid, the Joint Commission. Here are some example questions for an internal audit:

  • Does the note explain why the patient needed to be hospitalized that day?
  • Does the note explain the full complexity of the patient’s diagnoses?
  • Are clinician signatures legible?
  • Is first initial and last name of clinician documented, at minimum?
  • Is a history and physical documented in the chart within 24 hours of admission?
  • If a history and physical was performed in a physician office, is there an update documented in the hospital medical record?
  • Is there a history and physical on the chart prior to a surgical procedure?
  • If the patient’s history and exam suggested a safety issue (such as risk of fall), did a registered nurse, nurse practitioner, physician assistant or physician address the issue?
  • For the surgical patient, does the record reflect that a clinician marked the correct surgical site?

The package provides a rationale for each question and a scoring mechanism which can be used to track improvement or lack thereof. The audit analysis includes attention to systems issues, asking such questions as: How many places must an RN document during a shift? Is there duplication? Are there prompts?

Here is an example of 2 of the audit questions with rationale for the questions:

Audit question
Rationale for question
Does the note explain why the patient needed to be hospitalized that day? Medicare and other payers may deny payment for a DRG if an auditor finds the hospitalization to be medically unnecessary. Therefore, in each day’s documentation, there should be an indication of why the patient needed to be hospitalized that day.
Does the note explain the full complexity of the patient’s diagnoses? Some DRGs describe complicated illnesses while others describe simple conditions. For example, there is a DRG for simple pneumonia and another for complicated pneumonia. In order to use the DRG for complicated pneumonia, the medical record must document the aspects of the patient’s condition which are complicated. Hospitals want to capture the highest-paying DRG, but the documentation must support the DRG claimed.


An audit program would go something like this:
Day 1: Audit a sample of medical records written the previous day (Do it yourself or have my office do it onsite). In the evening, analyze the data.

Day 2: Present the findings, invite discussion and conduct training targeted to the results of the audit. (Do it yourself of have my office do it onsite.) The close timing of writing, audit and training increases the likelihood that the nurses will remember what was going on the day the notes were written.

Day 30: Re-audit. Compare results to the first audit. Develop additional training or retraining as called for by the results.

Advice for hospital executives:

I recommend that hospitals audit their own charts from time to time. I don’t recommend that anyone change entries; I advise against that. I believe that going over documentation with a set of evaluation questions in mind and following up with targeted training makes for better documentation in the future. Self-auditing should be a part of every facility’s routine. Identify problem areas, discuss the problems, follow up with targeted training and then re-evaluate. If you do this, you are on the road to quality improvement while avoiding disasters. It is so much better that a facility evaluate itself than wait until an outside observer finds mistakes. Avoid embarrassment and worse by taking a proactive approach.