Develop quality control procedures for documenting patient records.
A primary care physician and her partner, who have just opened their practice, newly employ you as a medical assistant.
You have been asked by one of the physicians to set up a process for doing chart audits. You know that one component of chart audits is to determine what is to be audited and the criteria for that audit. Distinguish between doing random and convenience sampling and give an example for each type.
A primary care practice is seen as the standard of managed care since it is responsible for preventive care and coordination of services by specialist for patients with chronic illnesses. More and more practices are focusing on the structure and content of the clinical record to fulfill the expectation for quality of services and contain the rising cost of medical care
The medical assistant should sit with the providers and explain that in general they can have two different audit processes; one that could audit charts for documentation completeness and accuracy; and a second audit process targeting specific prevention strategies and chronic illness management as part of a quality improvement initiative. S/he must emphasize that it is important to clearly define the criteria that will be use in the audit process. For example, for the audit that will check for documentation accuracy and completeness could include:
1)"Every page in the medical record should include the patient's name and identification number.
2)The contents of the medical record should have a standardized structure and layout.
3)Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order. Every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be ...
The solution includes discussion of two different medical record audit processes - one for documentation completeness and accuracy and another one targeting specific prevention strategies and chronic illness management - as part of a quality improvement initiative in a primary care setting.