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> clinical documentation audit
clinical documentation audit
Pre-audit Preparation
Review relevant policies and procedures
Ensure access to necessary documentation systems
Identify audit criteria and objectives
Patient Identification
Verify patient’s name and date of birth on all documentation
Check for consistency in patient identifiers across documentation
Documentation Completeness
Ensure all required forms and documents are present
Review for missing or incomplete sections in progress notes and assessments
Accuracy of Information
Verify accuracy of patient information, including vital signs and medical history
Confirm consistency in documentation of care provided
Compliance with Regulations
Check for adherence to legal and regulatory requirements
Review for proper documentation of controlled substances and other sensitive information
Timeliness of Documentation
Evaluate timeliness of charting, including progress notes and treatment plans
Ensure documentation is completed in a timely manner after patient encounters
Communication with Healthcare Team
Assess documentation of communication with other healthcare providers
Review for collaboration and coordination of care among team members
Quality of Clinical Reasoning
Evaluate documentation of assessment findings and treatment decisions
Confirm rationale for interventions and care plans
Follow-up and Continuity of Care
Check for documentation of follow-up appointments and referrals
Ensure continuity of care through clear documentation of handoffs and transitions
Post-audit Review
Summarize findings and identify areas for improvement
Develop action plan for addressing deficiencies and implementing changes
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