How to Do a Medical Chart Review

A miscoded billing note in a medical chart can cost your health care organization a lot of money. Performing medical chart reviews keeps you compliant with federal health care regulations by allowing you to spot and correct errors and omissions before the federal auditors catch them. In the health care practice, medical charts are reviewed for quality assurance purposes. The reviewer or auditor evaluates records to make sure that services rendered are coded accurately, billed accurately and that the treatment provided to the patient is appropriate for his diagnosis.

Things You'll Need

• Medical charts
• Audit tool

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Instructions

• 1

  Plan your medical chart review. Identify the focus and what it is you wish to learn through your audit. Health care professionals review medical charts for a variety of reasons, and the objective you identify allows you to target specific information in the chart, as well as create an appropriate tool for capturing quantitative data during your review. A medical chart review for coding accuracy warrants a different approach from that of a review for service quality.

• 2

  Develop your audit tool on a computer spreadsheet. To review a medical record you must use a tool that prompts you to look for particular pieces of information. The prompts are known as audit identifiers or questions, and are based on health care industry performance measures as created by state and federal health departments. Create a yes/no column on the audit tool spreadsheet, so that each question can be answered quantitatively by checking the "yes" or "no" column. The Health Plan Employer Data and Information Set (HEDIS) is the most common set of performance measures that health care professionals use to base their audit tools on.

• 3

  Determine your patient population. If you are performing a review on patients who take a particular medication, you must run a query to know which patient charts to pull for the audit. Come up with an appropriate sample size for your review.

• 4

  Study the medical chart. Take a few minutes to familiarize yourself with where certain information is in the chart. Medical charts store a lot of patient information, such as their medical history, assessments, insurance information and prescription lists. Your audit will be smoother and quicker if you know where to find the information you seek.

• 5

  Have your audit tool with you as you review the medical chart. Read the identifiers on the audit tool and search for the information in the record. Be thorough in your review, because it is possible for documents to be misfiled in a chart.

• 6

  Collect the data and summarize your findings. Come up with a score for your medical audit based on the results. Analyze the score to determine how compliant or noncompliant the charts are. A low score on a medical chart review signifies that quality improvement efforts are in order.