Audit Tool

Review Date:
Provider:
Location :
Reviewer:
Patient Name:
Contracted Provider
Medical Record Audit Tool
Last Review Date:
Clinic Name:
Contact Person Name:
Contact Person Phone:
Medical Record Format:
Patient DOB:
Question
Point
value
Do all pages contain patient ID/name/DOB? 0
Is there biographical/personal data? 0
Is the record legible? 0
Yes / No /
NA
Comments
Is there a complete/current problem list, which states
active/chronic illnesses and medical/psychological
conditions, including past medical history, physical
exams, necessary treatments, t t and possible risk factors
for the member relevant to the particular treatment?
0
Do chart notes contain presenting complaints, diagnoses,
and treatment plans?
0
Is there documentation of the following for members 14
years and older and seen 3 or more times:
•Tobacco habits 0
•Alcohol use 0
•Substance abuse 0
If medical record indicates patient uses tobacco, is there
documentation of advice to quit during the previous
year?
0
Page 1 of 4

Review Date:
Provider:
Location :
Reviewer:
Patient Name:
Contracted Provider
Medical Record Audit Tool
Last Review Date:
Clinic Name:
Contact Person Name:
Contact Person Phone:
Medical Record Format:
Patient DOB:
Question
Point
value
Yes / No /
NA
Comments
Does chart contain past medical history, physical
examinations, necessary treatments, and possible risk
factors for the member relevant to the particular
treatment?
0
Is there evidence that HIPAA privacy requirements are
met and that privacy information is provided to patients
and documented in the chart?
0
If the clinic has electronic medical records, do they have
screen savers with password protection to prevent
confidential information from being viewed by
unauthorized people?
0
Are documents in the medical record securely attached
in the chart?
0
Is there identification of all providers participating in the
member's care and information on services furnished by
these providers?
0
Do all chart notes generated by the provider under
medical record review include the date of service, a
legible signature, the provider's credentials, and
authentication by the provider (for any documents
generated by but not transcribed by the provider under
review)?
0
Is there documentation of preventive care? 0
Page 2 of 4

Review Date:
Provider:
Location :
Reviewer:
Patient Name:
Contracted Provider
Medical Record Audit Tool
Last Review Date:
Clinic Name:
Contact Person Name:
Contact Person Phone:
Medical Record Format:
Patient DOB:
Question
Point
value
Is there documentation of education of self-care? 0
Yes / No /
NA
Comments
Page 3 of 4

Review Date:
Provider:
Location :
Reviewer:
Patient Name:
Contracted Provider
Medical Record Audit Tool
Last Review Date:
Clinic Name:
Contact Person Name:
Contact Person Phone:
Medical Record Format:
Patient DOB:
Question
Point
value
Is there a current medication profile? 0
Yes / No /
NA
Comments
Is there a current allergy and adverse reaction profile?
0
Is it clear and prominently indicated that an inquiry has
been made regarding a patient's advanced directive? 0
Are age-appropriate immunization records
present/current?
0
Is there documentation of follow up care? 0
General Comments:
0 0
Scoring:
To achieve a passing score, the following threshold must be met: ≥80%
Elements 0 #DIV/0! #DIV/0!
Page 4 of 4