Does the thought of a chart audit send shivers down your spine? Or does it simply bore you to tears?
Many physician offices perform chart reviews only in time of trouble, usually when increasingly-aggressive RAC Audit or insurance companies require a review. Routine chart audits, however, are an excellent tool to improve quality of care, check the performance of physicians, measure the overall operations of the medical office and to identify aspects of your practice that need improvement.
Medical records reflect more than the health of a patient – these records also hold valuable clues about the efficiency of your medical practice. If you are frustrated with a particular clinical process that is not working well, for example, you might use a chart audit to document the problem and assess its magnitude across your practice. Performing a chart review can help you develop an answer.
You can conduct a chart audit to study virtually any aspect of patient care, as a great deal of the patient experience is documented in a medical record. Chart audits can also save you money. Your practice may lose thousands of dollars each year through poor coding or skipped billing.
Step 1: Pick a topic
Choose a topic of interest to your practice. Pick one that is neither too broad nor too narrow. The topic of ‘breast cancer consultations’ may be too general, for example, while reviewing charts for the number of women who have trouble performing self-exams may be too narrow.
If your chart review team flounders during an audit, reassess your topic – chances are it is too narrow or not specific enough.
Step 2: Identify units of measure
Determine appropriate measures for the topic. In our example topic of breast cancer, you might use the number of women who say they perform self-examinations as a unit of measure.
Create specific guidelines for these measures. Identify the threshold for meeting criteria – determine what constitutes a “met criteria” and what does not. For example, does a report of self-examination alone meet your criteria for a successful breast cancer consultation? Some would say a breast cancer consultation is only complete after the practitioner performs an exam or discusses breast cancer with the patient.
It may be helpful to review other literature to help you determine measures for the study. HEDIS is always a good place to start.
Step 3: Indentify patient population
Define the records you wish to review. Consider the age, gender, disease status and treatment status. In many cases, the topic helps you determine your patient population.
Step 4: Determine sample size
Auditing every patient chart is simply not feasible. A good rule of thumb is to review about 10 percent of eligible charts, but you can review as few as 10 – 20 charts. Duke University Medical Center provides an excellent tool for determining a statistically valid sample size.
Step 5: Arm yourself with audit tools
You will need instruments to document your findings – spreadsheets are ideal because they allow for easy data compilation and calculations of rates, percentages, means, and other statistics. For even greater accuracy and ease, use a professional audit and medical documentation review program.
Step 6: Collect data
Data collection is the “grunt work” of chart audits. Reviewers determine whether the individual meets the criteria for the audit and completes one audit tool per patient.
Step 7: Summarize results
Summarizing results is more than adding up data sheets. Before summarizing your results, consider how you will use the data. Create a summary providing data your clinic can use to improve quality of care in a meaningful way.
Step 8: Analyze and apply results
Compare your compiled data with known benchmarks, either from within your own clinic or from other sources. For example, you may learn that 75 percent of Black/African American women who visit your clinic have had a mammogram in the past two years, higher than the national average.
Chart audits are perhaps the best way to get feedback on the quality of care your practice provides. Get your practice in the habit of performing chart reviews to improve the quality of care – and the bottom line – of your practice.