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Importance of Clinical Chart Auditing

With constant changes within healthcare environment and a shift from volume to value, healthcare organizations need to rethink their use of internal audit. Healthcare organizations must be willing to expand their internal audit to include clinical chart auditing.


Hospitals and healthcare providers lose millions of dollars every year due to mismanagement of the billing process. This ranges from inaccurate charging, such as undercharging for a service or procedure or missing a charge altogether. Accurate charge capture processes will improve cash flow and increase revenue which adds up to a healthier bottom line satisfying regulatory compliance.


A clinical chart audit is an in-depth examination of medical records to ensure that all ancillary services, surgical procedures, supplies, medications, etc. were ordered & delivered to the patient as charged and promoting accuracy and integrity of hospital charges and assist in recovery of lost revenue.


Every Revenue generating department within any healthcare organization must properly document and record charges in order to establish control mechanisms to ensure that appropriate procedures and charging protocol are being followed.


One reoccurring question is often asked is how often to review and what sample of chart needs to be reviewed. A great practice for any healthcare organization is to perform concurrent audits to identify charges that may indicate deficiencies in charge pathways and processes. A concurrent audit is defined as a complete audit on a non-disputed account, completed within 30-days of patient discharge. The audit sample should be random query to be determined by the facility/client.


A complete concurrent audit conducted by an experienced nurse auditor, not only provides a precise audit detail with audit outcomes, it should also provide a detailed monthly audit statistic report to identify departments showing a trend of over charges and under charges including departmental error rates. These audit statistic reports, help to identify the reasons why the over and under charges are occurring and can further assist departments in creating a corrective action plan for resolution to prevent errors from reoccurring.


In conclusion, a chart audit is an examination of your facilities charging, documentation, and policies to determine at risk areas in your systems practice and improve a healthy financial system.

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