Medical Record Audit

This inspection checklist can be used by auditors to spot-check paper or electronic medical records, in order to ensure they are complete, error-free and compliant.

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Medical Record Audit

Medical Record Details

Criteria - Paper Based Medical Record

Criteria - Electronic Medical Record

Criteria - Host Access Patient Registration Screen

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Medical Record Audit

This inspection checklist can be used by auditors to spot-check paper or electronic medical records, in order to ensure they are complete, error-free and compliant.

1. Medical Record Number

1. Identification completed on All Consultation Report pages (patient label is ideal)?

2. Correspondence filed for the correct patient?

3. Results filed are for the correct patient?

4. Patient labels are correct and current?

5. Medical record file / cover is in good working order?

6. Are the documents in reverse chronological order (most recent on top)?

7. Are the documents separated into appropriate tabs?

1. Is pathology labelled / filed correctly?

2. Is diagnostic imaging labelled / filed correctly?

3. Are electronic letters corresponding to the correct patient?

4. Are scanned documents corresponding the correct patient?

5. Are Electronic Letters forwarded or sent back or distributed appropriately?

1. General Practitioner name or details recorded on Patient Registration Screen?

2. Marital status is recorded on Patient Registration Screen?

3. Title is recorded on Patient Registration Screen?

4. Next of kin recorded?

5. If deceased is the record marked "deceased" on Patient Registration Screen?

6. If deceased, is the record marked "Estate of" on Patient Registration Screen

7. If deceased, is the Date of Death recorded?

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Medical Record Audit

This inspection checklist can be used by auditors to spot-check paper or electronic medical records, in order to ensure they are complete, error-free and compliant.​

1. Medical Record Number

1. Identification completed on All Consultation Report pages (patient label is ideal)?

2. Correspondence filed for the correct patient?

3. Results filed are for the correct patient?

4. Patient labels are correct and current?

5. Medical record file / cover is in good working order?

6. Are the documents in reverse chronological order (most recent on top)?

7. Are the documents separated into appropriate tabs?

1. Is pathology labelled / filed correctly?

2. Is diagnostic imaging labelled / filed correctly?

3. Are electronic letters corresponding to the correct patient?

4. Are scanned documents corresponding the correct patient?

5. Are Electronic Letters forwarded or sent back or distributed appropriately?

1. General Practitioner name or details recorded on Patient Registration Screen?

2. Marital status is recorded on Patient Registration Screen?

3. Title is recorded on Patient Registration Screen?

4. Next of kin recorded?

5. If deceased is the record marked "deceased" on Patient Registration Screen?

6. If deceased, is the record marked "Estate of" on Patient Registration Screen

7. If deceased, is the Date of Death recorded?

Get started on a free trial

Is GoAudits right for you?

Trusted by 600+ businesses globally

Book Intro Call

This inspection checklist can be used by auditors to spot-check paper or electronic medical records, in order to ensure they are complete, error-free and compliant.