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Medical Record Audit Checklist Template

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Medical Record Audit Checklist Template

Audit

Medical Record Details

Medical Record Number

CRITERIA - PAPER BASED MEDICAL RECORD

Identification completed on ALL Consultation Report pages (Minimum: First name, Last name, DOB) Patient Label is ideal
Correspondence filed are for the correct patient
Results filed are for the correct patient
Patient labels are correct and current
Medical record file / cover is in good working order
Documents are in reverse chronological order (most recent on top)
Documents are separated into appropriately tab eg. Results tab

CRITERIA - ELECTRONIC MEDICAL RECORD

Pathology is labelled / filed correctly
Diagnostic Imaging is labelled / filed correctly
Electronic letters are for the correct patient
Scanned documents are for the correct patient
Electronic Letters - FORWARDED
Electronic Letters - SENT BACK
Electronic Letters - DISTRIBUTED

CRITERIA - HOST ACCESS PATIENT REGISTRATION SCREEN

General Practitioner is recorded on Patient Registration Screen
Marital status is recorded on Patient Registration Screen ( if known)
Title is recorded on Patient Registration Screen
Next Of Kin is recorded
Copy To Doctors are on Referral Screen
If Deceased, record is marked "deceased" on Patient Registration Screen
If Deceased, record is marked "Estate of" on Patient Registration Screen
If Deceased, Date of Death is recorded
Signature
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