Question

You are the HIM Director at Acme Hospital a 300-bed facility. Acme specializes in cardiac care and treats approximately 750 patients a month. You have been tasked with designing a chart audit tool to show compliance with these standards. Select 10 standards that you feel are important to illustrate compliance with documentation within the medical record. This chart audit tool (form) should act as a data collection tool for analysis of compliance. Some things to think about while you are designing your form: What patient identifiers will you include? While meeting ALL of the standards is important, what 10 do you think are the most important?

Answer 1

The ten standards which are very important in the chart audit at Acme cardiac center are:

1. Medication Safety Standard.
2. Comprehensive Care Standard.
3. Clinical Governance Standard.
4. Partnering with Consumers Standard.
5. Preventing and Controlling Infections Standard.
6. Communicating for Safety Standard.
7. Blood Management Standard.
8. Recognising and and Responding to Acute Deterioration Standard
9. Diagnosing standard
10. Financing standard

What is chart audit tool?

A chart audit can be defined as the standards which physicians or healthcare personnels used to check their own performance as to how well they discharging their duties and how they can improve on weakness

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