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Separating Fact from Fiction in Healthcare Medical Chart Auditing

November 23, 2016


Chart auditing programs have become more important in light of increased federal payer audits.  As a result, many providers want assurances that their medical chart documentation is accurate and is descriptive of the provided medical services.  Validating processes and functions in a healthcare setting follows the same principles as fact checking a news story.  Medical chart auditing is analogous to fact checking political promises or even validating a tabloid claim.


Auditing As a Strategic Initiative


Performing internal audits plays a critical role in healthcare.  Providers must ensure that health record documentation supports the level of services stated in the medical record.


Delivering quality healthcare requires accurate and comprehensive clinical documentation in the medical record.  The best way to improve the documentation and financial health of your organization is through medical record audits.  They are essential to determine areas that require improvements and corrections.


Audits positively affect the efficiency of care delivery and streamline basic functions.  Medical record audits specifically document procedural and diagnosis code selections determined by physician documentation.  Once an audit reveals inaccurate areas that necessitate corrections, the discoveries provide a foundation for training and monitoring future documentation.


Principles and Standards of Auditing


The following outline attributes that all auditors should possess.  They are:


  • Integrity – Auditors must establish trust.  That is the basis for reliance on their judgment.
  • Objectivity – Auditors must exhibit professional objectivity in collecting, evaluating and sharing information. 
  • Confidentiality – Auditors respect the value and ownership of information.  They do not disclose information without appropriate authorization unless they have a legal or professional obligation.
  • Competency – Auditors apply the knowledge, experience and acumen required to perform audits.


Requirements for Chart Auditing

There are four key reasons why chart audits are necessary as a part of the delivery of care.  They are:


  1. Measurement requirements:  The Health Plan Employer Data and Information Set is the most widely used set of performance measures in managed care.  On an annual basis, health plans are required to report various sets of measures.  Employers and prospective members can then evaluate plans based on their quality of care.  Other measurements include process-specific audits such as medical chart auditing.
  2. Administrative requirements:  Federal rules and regulations require medical records documentation to validate charges coded and billed.  Also, chart audits are used to measure compliance.
  3. Research and Validation:  Medical records contain data that may be useful in research by measuring the prevalence of symptoms and diseases compared to the results of treatment strategies.
  4. Quality Improvement Measurements:  Chart Audits assess adherence to policies and compliance of regulation for procedures and methods of care.  Providers use chart audits to measure the quality of care to improve it.  Quality initiatives are typically small-scale assessments designed to improve processes, outcomes and efficacy of systems across the healthcare continuum


Audit Trails


Audit trails document the name of the auditor, the application triggering the audit, the workstation, and the specific document, a description of the audit event and the date and time.  An audit trail must capture all amended data within the health record and provide auditors with a starting point for compliance audits.


Organizations may utilize the audit trail functionality of an electronic health record to identify and trend utilization of health records.  The functionality typically allows users to generate reports for a specified period by provider or provider type, with the results that are made available to compliance personnel.




Every organization must determine the processes to monitor and audit medical records.  It is critical to address the requirements of applicable laws and regulations when building a compliance program.  Every organization is responsible for specifying the method for determining the legitimacy of an activity or one that is suspect.  Leading indicators for compliance risk are:

  • Abnormal patterns of activity
  • Routine documentation monitoring
  • Routine coding monitoring and auditing
  • Monitoring the assignment of codes according to applicable coding system guidelines
  • Auditing of electronic health record (EHR) access and documentation
  • System-generated warning messages related to attempted unauthorized access
  • Monitor software upgrades and system changes


Maintaining Integrity

Organizations should have policies and procedures in place that prevent fraud and the falsification of information.  Organizations should consider the following:

  • Purchasing systems that include functions and capabilities to prevent or discourage fraudulent activity
  • Implementing policies, procedures and system functions to prevent fraud
  • Fraud prevention education
  • A standard set of business rules for EHR systems


Education and Training for Fraud Prevention

Educational programs need to identify specific processes within the EHR that stakeholders must follow.  Training should focus on areas where there are potential fraud risks.  Comprehensive education and training programs should include two areas of focus:

  1. Initial and ongoing education and training:  The organization is responsible for ensuring that all users receive regularly scheduled education and training.  The training programs should include a review of organizational policies and procedures.
  2. Educational programs need to address the organization’s disciplinary and termination policies governing falsification of records, security and access breaches, or violations.  In addition, programs should also follow the organization’s Health Insurance Portability and Accountability (HIPAA) Act.  All guidelines relating to handling and sharing of patient health information must be in accordance with the security of health information rules and regulations.



Quality healthcare relies on accurate and detailed clinical documentation of the medical record.  Medical chart audits are designed to enhance the delivery of care, improve safety efforts and increase financial returns of the healthcare provider.  Auditing must be an essential part of a health organization’s foundation and structure for defining the measurements and criteria for proper medical documentation.  Sometimes it is difficult to separate fact from fiction when undertaking medical chart audits.  The job of a good medical chart auditor is to evaluate all accessible data, determine if there are any missing elements and confirm its correctness.

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