Here is a list of the most common Medical Record errors to keep in mind during your chart audit review:
- Whether or not your center honors advance directives make sure the patient attest to what is on your form for example; if you have a form that ask the patient “Do you have an advance directive?” If they state yes, get a copy of it and include it in the medical record. Ensure you have the acknowledgement of the execution of the advance directive. Make sure that the patient has signed all acknowledgement forms.
- Make sure your document all allergies and REACTIONS to the allergies. Documentation of allergies and reactions occurs on the front of the chart (the red sticker), H & P, nursing assessment and anesthesia record. Once you are fully on EMR you will still require to have the red sticker for the purpose of transferring a patient. You will need to print a copy of the medical record to provide to the transferring hospital.
- If there is an area on the forms where you have to record the date and time please do so.
- Ensure all operative reports are signed. Some surveyors like if the operative report is more than two pages for the surgeon to initial each page and sign the last page.
- Patients have the responsibility to provide a responsible adult to transport him/her home from the facility. Make sure you write the responsible adults name in the discharge notes.
Here’s to your success,