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
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!
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