ARA Medical Record Audit

Are you providers compliant with their medical records?

An ARA-conducted medical record audit can help eliminate risks and issues that may limit the profitability of a health plan. Problems can rise from improper and careless record keeping. Inaccurate medical records can even endanger the lives of the patients. Proper maintenance of all the tasks related to clinical documentation must be executed.

An ARA-conducted medical record audit can:

• Identify items that require improvements and corrections.
• Provide recommendations for the right clinical documentation improvement program to simplify clinical documentation.
• Ensure systematic and highly organized operations to benefit all parties involved with the health plan.

Some of the items ARA auditors identify include:

• Do all pages [of the medical record] contain patient name or ID#?
• Does the record contain the address, home and/or work phone, employer, marital status, gender, next of kin and date of birth?
• Are all the enteries dated? Is the record legibible?
• Does the medical record contain sufficient information to identify a patient, support diagnosis, justify treatment, and document results accurately?
• Are the medical records kept confidential? Are they current, authenticated, legible and complete?
• Are they kept in a secure environment?
• Does the staff receive adequate direction, staffing and equipment to perform required functions?

ARA holds itself to high standards, provides ethical services and follows all applicable laws and regulations in with its clients, while providing exceptional quality service for an affordable price.