Medical Record Audit
Complete per audit schedule.
- Industry: Healthcare
- Frequency: Monthly / Quarterly
- Estimated Time: 30-60 minutes per record
- Role: HIM / Compliance
- Total Items: 30
- Compliance: Joint Commission, CMS, HIPAA
Documentation
Check documentation.
- Documentation legible?
- Entries authenticated?
- Documentation timely?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
Environment of Care & Safety
Verify facility environment meets safety standards
- Fire exits clear and unobstructed?
- Emergency equipment functional and accessible?
- Spill kits available and stocked?
- Electrical cords and outlets in safe condition?
Documentation & Regulatory Compliance
Complete assessment documentation and ensure regulatory compliance
- All findings documented with evidence?
- Corrective actions assigned with timeline?
- Staff education provided on identified issues?
- Assessor Signature
- Additional Observations
Related Healthcare Checklists
- Emergency Preparedness
- Pharmacy Compliance Audit
- Laboratory Compliance Audit
- Provider Credentialing
- Patient Flow Management
- IV Admixture Preparation
- Healthcare Facility Environmental Safety
- Life Safety Inspection
Related Healthcare Compliance Checklists
- OSHA Healthcare Standards Audit - FREE Download
- CMS Conditions of Participation - FREE Download
- Emergency Preparedness - FREE Download
- Pharmacy Compliance Audit - FREE Download
- Laboratory Compliance Audit - FREE Download
- Provider Credentialing - FREE Download
- Informed Consent Audit - FREE Download
- Radiology Compliance Audit - FREE Download
- Ethics Consultation Review - FREE Download
Why Use This Medical Record Audit?
This medical record audit helps healthcare teams maintain compliance and operational excellence. Designed for him / compliance professionals, this checklist covers 30 critical inspection points across 7 sections. Recommended frequency: monthly / quarterly.
Ensures compliance with Joint Commission, CMS, HIPAA. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Medical Record Audit cover?
This checklist covers 30 inspection items across 7 sections: Documentation, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management, Environment of Care & Safety, Documentation & Regulatory Compliance. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed monthly / quarterly. Each completion takes approximately 30-60 minutes per record.
Who should use this Medical Record Audit?
This checklist is designed for HIM / Compliance professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.