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Chart Audits & Clinical Records Review

Ensure Documentation Appropriateness and Compliance

Our chart audits are conducted in three stages: initial data review, on-site assessment, and off-site report composition. The central goals of the audits are to ensure compliance to regulations and appropriate reimbursement.

What's Included:

Initial Data Review

In order to understand the current state of the facilities, the team will review information including the following:

  • Past surveys
  • Previous denials
On-site Assessment

Prior to the visit on site, the Client will provide the full array of medical record numbers for the Soyring team to draw from. The Soyring team will compile a statistically valid, randomly selected sample of records to review. The set of selected records will be requested upon arrival at the facility.

The consultant(s) will review the charts’ following attributes to ensure compliance with regulations including Medicare, Medicaid, and others:

  • Doctors’ orders
  • Medicine Administration Records (MARS)
  • Treatment Administration Records (TARS)
  • Observation of treatment rendered to patients (is care being administered as documented and vice versa)
  • Provider Preventable Conditions (PPCs)

The team will also review associated policies and procedures for both regulatory requirements and protocols specific to the healthcare facility.

Off-site Report Composition

Following the data review and on-site assessment, the Soyring team will compile and compose the final report to present to the Client and its leadership team. This report encompasses all findings and recommendations, including any final feedback received from the Client during the exit interview at the end of the on-site assessment phase.

 

Featured Resource:

FREE WHITE PAPER

Redesigning Case Management to Improve Quality Outcomes and Reduce Readmissions for Clients with Chronic Disease

“I’ve had long-term relationship with Soyring’s leadership and consulting staff through Denice Higman. I know that they would provide consultants with the knowledge and expertise that I can count on. I have been thrilled with the consultants that we have worked with and I feel I have always been supported with some of the best consultants they have to offer.”

SENIOR VP AND CNO, COMMUNITY HOSPITAL

Learn How Our Experienced Team Can Improve Charting at Your Hospital or Healthcare Facility.

Contact us today at 1.866.345.3887 or simply fill out this form & we will contact you.