Get Audit Form

Filling out the Audit Form online is a straightforward process that ensures thorough medical record evaluations. This guide will assist you in navigating each section and completing the form accurately.

Follow the steps to successfully complete the Audit Form.

1. Click ‘Get Form’ button to access the Audit Form and open it for editing.
2. In the first section, provide the name of the doctor in the 'Dr’s Name' field. Ensure you spell the name correctly for accurate documentation.
3. Next, enter the patient's name in the 'Patient’s Name' field, ensuring it matches official records.
4. Fill in the 'Review Date' field with the date of the audit. Use the format MM/DD/YYYY for consistency.
5. In the 'Reviewer' field, include your name as the person conducting the audit.
6. Proceed through the review criteria, addressing each point methodically. For example, check if the chart is well-organized and provide details for each sub-question.
7. Continue to assess all entries for signature and date, ensuring legibility and prompt transcription are noted.
8. Review and confirm the allergy list is up-to-date. Mark whether it is visible.
9. Ensure the medication list is current, noting if sample medications are included.
10. If the review is for a primary care provider, verify the problem list is complete and updated.
11. Check diagnostic test results for initials and confirm patient notifications of results are documented.
12. Document all patient communications, including calls outside of regular hours.
13. Note any missed, canceled, or rescheduled appointments, documenting them accurately.
14. Ensure patient education is documented, including both instructions given and printed materials.
15. Review the findings to confirm they support the diagnoses made, noting whether treatment addressed these diagnoses.
16. Document any informed consent and informed refusal, ensuring clarity on each patient's decision.
17. If referrals to specialists were made, record the evidence of those consultations and continuity of care.
18. Finally, ensure any corrections made to the records are properly documented.
19. Once all sections of the form are filled out, save your changes. You can also download, print, or share the form as needed.

Complete your Audit Form online today to ensure a comprehensive review.