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This form outlines the procedures and criteria for conducting chart audits on CITYTECH e-charts as part of the quality assurance process. It provides instructions for faculty and students on the expectations for documentation, clinical notes, data collection, medical and dental history, and the audit process following treatment sessions.
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What is chart audit form?
A chart audit form is a document used to systematically evaluate the accuracy, completeness, and quality of a healthcare provider's medical records.
Who is required to file chart audit form?
Healthcare providers, such as physicians and nurses, as well as administrative staff responsible for maintaining patient records, are typically required to file a chart audit form.
How to fill out chart audit form?
To fill out a chart audit form, review the medical record for accuracy, completeness, and compliance with established standards, then document findings on the form, noting any discrepancies or required improvements.
What is the purpose of chart audit form?
The purpose of a chart audit form is to improve the quality of patient care by identifying areas for improvement in documentation, ensuring compliance with legal and regulatory requirements, and enhancing overall clinical performance.
What information must be reported on chart audit form?
The information that must be reported on a chart audit form includes patient identification, date of service, a summary of the chart contents, any identified issues or discrepancies, and recommendations for corrective actions.
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