The Importance Patient Chart Documentation

ABC requires compliance with all accreditation standards but non-compliance with some of the standards will result in a Corrective Action Plan (CAP). One of these standards is CB.4, which requires that you establish file auditing and monitoring procedures for clinical and financial records.

Under CB.4.1, you must have an ongoing patient chart auditing and monitoring procedure as part of your claims and billing compliance program. This means you need to evaluate the results of your compliance program and act on any necessary changes. This standard is crucial in ensuring that your facility is complying with all applicable regulations and laws.

One of the ways you can comply with CB.4 and 4.1 is by establishing an internal patient chart audit. This involves randomly selecting several charts and checking them for complete financial and clinical documentation. The audit should document any missing requirements along with the follow-up steps that you will take to ensure future compliance. A sample of charts from each practitioner should be selected for the audit to ensure it is as comprehensive as possible.

It's important to note that an internal patient chart audit is different from a billing and coding error log (PM.6), since this audit should also incorporate the clinical documentation that was recorded. The patient chart audit should cover all aspects of documentation.

The patient chart audit is required annually. If one has not been performed within the last year and you are surveyed during that time, you will be required to submit a CAP with documentation that one has taken place.

You can create your own documentation tool for auditing your patient charts, or you can utilize our Patient Chart Audit form available in the Compliance Kit Resource Pack.