Q&A: Chart audit focus areas

Q: What topics should routine chart audits focus on?

A: Chart audits should be conducted on a regular basis to ensure that documen- tation is complete and accurate and that codes and charges are appropriately assigned. Chart audits should include the following four actions:

1. Audit medical records against charges and claims to make corrections and improvements in charge capture, coding accuracy, billing, medical necessity, or documentation
2. Audit patient charts and medical records to evaluate adequacy of clini- cal documentation, compliance, reasons for treatments, billed services/ items, coding, payments, operations, or completeness of bill
3. Review medical records for accuracy and billing compliance
4. Review hospital (or other healthcare facility) department medical record documentation for improvement opportunities as part of a scheduled periodic review process

For more information, see the CHRI Exam Study Guide.