Sample Quality Chart Review Tool printable pdf download

Quality Chart Review Tool

Rationale

This document is designed to use as an audit tool in conjunction with your Documentation Policies

and Procedures. We recommend that Documentation Policies and Procedures include a deﬁnition of

the components of the medical record and chart entry guidelines for each patient encounter.

The tool will provide a method to proactively identify risks related to

documentation practices.

Chart review is a key element of performance measurement for ofﬁce practice and involves

reviewing a representative sampling of patient charts for each practitioner. This tool

can also be used to collect data for quality improvement initiatives.

The medical record is the ofﬁcial record of the care of the patient; therefore, gaps in

documentation should be avoided.

Quality chart review is a three step process to improve quality and reduce risk exposure. The

tool is the ﬁrst step and is the method to collect the data. The second step is data analysis and

the third step is action predicated on the analysis.

Analysis of the data can be displayed through graphics. For example, a compliance goal

can be set at 100% and then each criterion can be measured and related to the goal. The

results will assist you in focusing and prioritizing improvement action plans. Quality

review information can be used to augment documentation and position the physician for

immediate participation in future Pay for Performance initiatives.

Rationales and the tools are not legal advice and are not meant to substitute for medical judgment. You may have other tools,

systems or protocols in your practice which may make this tool, or a part of it, unnecessary. Further, the tool, or parts of it, may

not be applicable to your specialty or practice. You should use or adapt the tools only if appropriate for your practice.

You should always consult your own legal counsel for current legal advice as laws and regulations may change.

Sample Quality Chart Review Tool