Lumiform
Mobile audits &
inspections

Get an overview of the most important features in Lumiform.
Turn issues into corrective actions by collaborating with team members.
Create custom checklists and use logics to predefine workflows.
Share automatically generated reports and get in-depth analytics.
Quickly conduct inspections with the easy-to-use inspection app.
Easily adapt the Lumiform software to your complex organization structure.

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Medical Record Audit

A medical record audit is a systematic review of patient health records to assess their accuracy, completeness, and compliance with legal and regulatory standards.

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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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Understanding the Importance of Medical Record Audits


A medical record audit is a crucial process that involves a comprehensive review of patient health records to evaluate their accuracy, completeness, and adherence to regulatory guidelines. This systematic examination plays a vital role in ensuring the quality of patient care, billing accuracy, and overall compliance within the healthcare industry.


Medical record audits serve several important purposes. Firstly, they help identify any documentation errors, inaccuracies, or omissions that may impact patient safety and quality of care. Additionally, audits play a vital role in ensuring proper coding and billing practices, preventing fraudulent activities and ensuring fair reimbursement. Moreover, audits assist healthcare organizations in maintaining compliance with legal and regulatory standards, such as HIPAA and billing guidelines set by insurance providers and government agencies.


In conclusion, medical record audits are an essential aspect of healthcare quality assurance and compliance. They ensure accurate documentation, proper coding, and adherence to regulations, leading to improved patient care, enhanced billing accuracy, and reduced legal and financial risks. Regular medical record audits contribute to maintaining the integrity and efficiency of healthcare organizations while prioritizing patient safety and delivering high-quality care


Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.