Chart Audits

Toolkit for Improving Your Office Testing Process

The Chart Audit Tool can help you assess how well your office enters information about tests and test results in the patient's medical record. Good documentation makes information readily available.

Use this tool to collect data to track different tasks throughout the testing process, including how well abnormal results are managed.

Using the Tool

  • You should be selective in how you use this tool. The way you use the Chart Audit Tool will depend on the information you need to collect for your project. This tool will help you collect data on:
    • Documentation.
    • The time it takes to move through tasks in the testing process.
    • Reporting normal and abnormal results to patients.
  • You need to identify the problem you want to investigate and adapt the audit tool to suit your needs.
  • Staff may choose to focus on a particular type of test or the performance of a particular laboratory.
  • The number of charts you audit will depend on:
    • How easy it is to identify patients with tests and/or critical abnormal results.
    • How much time your staff can devote to identifying charts, auditing charts, and compiling and interpreting results.
  • A minimum of 10 audits is recommended for both before and after testing; 20 audits will provide a more reliable measurement.
  • You will complete the appropriate sections of the audit form for each patient's medical record.
  • It is important to record the patient's name/ID number and the type of test, as this information may be needed if you discover a patient safety problem.
  • You may find it useful to know the type of test performed, particularly if your office uses different labs.

For projects about documentation: Photo depicts a male health care provider reviewing a medical chart in a file room.

  • Check the "yes" and "no" options to indicate whether information is recorded in the patient record. If you are uncertain, the accepted practice is to check the "no" option.
  • Place (overlap) the completed audits so the "no" responses are visible on multiple pages (Figure 5).
  • Many "no" responses to the same question point to an area where tasks are incomplete, and errors are more likely to occur.
  • Design a change to reduce error in your office system by using the Planning for Improvements Tool. After implementing the change, use the Chart Audit Tool again to determine if your office system has improved.

Figure 5. Aligning data sheets for review

Figure shows sample copies of the data sheets.

For projects concerned with time intervals within the testing process:

  • Fill in the appropriate dates as recorded in the medical record.
  • Be consistent in how you count the number of days. Decide whether or not to include weekends in the total number of days.
  • For each audit form:
    • Calculate the number of days between the date of test order and the date the result was recorded in the chart.
    • Calculate the number of days between the date the result was recorded in the chart and the date the patient was notified.
  • Compile the intervals from all forms and calculate the averages.
  • Identify any specific results within an interval that are greater than the average.
  • Discuss these results with your staff, and determine if they are acceptable or whether the variation reflects a problem with the office system.
  • Design a change to reduce error in your office system by using the Planning for Improvements Tool. After implementing the change, use the Chart Audit Tool again to determine if your office system has improved.
  • Results from different tests may arrive on different days, so you may want to focus on a specific test.

Chart Audits and Patient Safety

We know that:

  • Chart audits are widely used to provide information about office systems.
  • Chart audits rely on documentation, which may not accurately reflect actual care or practice.
  • Electronic health records automate many processes but do not eliminate all errors.
  • A failure to monitor automated processes may introduce patient safety risks.

Chart Audit Tool

Date of Audit: ______________________________

Instructions: Use one form for each test.

Enter all available information about a specific test from each medical record.

Patient Name & IDType of Test
 ___ Blood test   ___ Non-blood test  ___ Imaging (CT, MRI, x-ray, etc)
___ Mammogram ___   Other______
1. Is there an order for this
test in the patient's chart?
Date ordered
______________
yes ______ no
2. Is the test result in the
chart?
Date result recorded
______________
yes ______ no
   Is the signature dated? yes ______ no
3. Is there evidence in the
chart of the response to
the test result
(e.g., normal, further
testing, etc)?
 yes ______ no
4. Is there documentation in
the chart that the patient
was notified of the test
result?
Date patient notified
______________
yes ______ no
5. Is there documentation
that the patient
was notified of the
followup plan?
 yes ______ no
6. Is there documentation
that the patient acted on
the followup plan?
 yes ______ no
For abnormal results on the following test(s):

___ Pap smear   ___ Mammogram   ___ INR   ___ Other _____________

1. Was the patient notified of
the abnormal result within
the timeframe specified by
your office policy?
Date patient notified
______________
yes ______ no
2. Did the patient receive
followup care within the
timeframe specified by
your office policy?
 yes ______ no
Current as of August 2013
Internet Citation: Chart Audits: Toolkit for Improving Your Office Testing Process. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/office-testing-toolkit/officetesting-toolkit9.html