Std Medical Record Audit Tool Template
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3STD Medical Record Audit Tool
AUDIT DATE: ______________________
County: ______________________________
MONITOR: ________________________
Instructions:
Obtain a copy of the billing sheet for the most recent STD visits within the past 4 weeks.
If information should be present and is not, place “0” in the box
If information is present place a “√” in the box
If the information is not applicable place “NA” in the box
Chart Number
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Primary Provider ID
Legal Elements of Medical Record Documentation
HIPAA consent is signed in accordance with agency
policy
Declination of service is signed if applicable per
agency policy
Pages have client ID on both sides
Entries are legible
Entries are dated
Entries are recorded in chronological order
Entries are signed with name and title of staff making
entry:
Interviewer, if not the clinician
Clinician
Treatment nurse, if not the clinician
Health Educator
Social Worker
Others
Specific Areas of Review Medical Record
Telephone calls, letters, home visits, etc. are
documented to reflect agency policy regarding client
follow-up for additional therapy, test of cure, etc.
Chart is organized per agency policy
Allergies and adverse drug reactions are prominently
noted
Special service requirements are prominently noted
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N.C. Division of Public Health
Epidemiology Section
Communicable Disease Branch
DHHS EPI STD Medical Record Audit Tool-Draft
March 2013
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