Medical Record Chart Documentation Review
A St. Clair Senior Consultant performs, on-site, 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 checks 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.
In the course of performing the review, St. Clair drafts a “case by case” Excel spreadsheet regarding its findings and a draft narrative report which is forwarded for client review prior to an on-site exit conference. After resolving all of the client’s questions regarding the audit findings and recommendations, St. Clair issues 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.
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.