Medical Record Chart Documentation Review


St. Clair will perform, on-site generally on a quarterly basis, a combination "open record and closed record" review of medical record chart documentation for a healthcare facility’s inpatient cases, ambulatory surgery cases, and emergency room & urgent care visits. The sample records for review are selected to cover all clinical specialties. Using its Medical Record Chart Audit form, St. Clair will check for proper chart documentation in such areas as emergency & urgent care records, informed consent, history & physical protocol, pre-operative protocol, pre-anesthesia evaluation, operative report, post-operative protocol, intra-operative anesthesia protocol, post anesthesia follow-up, pathology & other diagnostic reports, physician orders, progress notes, medication records, discharge summary, and discharge instructions.


To complete the review, St. Clair will conduct an on-site exit conference regarding the "medical record chart audit" findings and recommendations. After completion of each quarterly on-site audit, St. Clair will prepare a draft of the final report on the audit findings and recommendations, with supporting documentation, and will provide a copy to the healthcare facility within two weeks thereafter. Only after resolving all of the facility’s questions regarding the audit findings and recommendations, will St. Clair issue the final report.


    Such medical record chart documentation reviews enables a healthcare facility to assess its own compliance with JACHO standards and elements of performance. Such reviews enable a healthcare facility to demonstrate evidence of standards compliance after it has been cited by JACHO to not be compliant with the standard on medical record chart documentation.

Pricing Approach

   The St. Clair professional fee for a "medical record chart documentation" review is competitively priced on the basis of the on-site consultant days, plus out of pocket expenses.