Ensuring that medical records are accurate and complete is another compliance challenge for physician medical practices. Physicians must take steps toward implementing internal controls that evaluate and rate the quality of medical records in their practice. Remember that poor medical record documentation can trigger an audit by payers and regulators, can destroy a physician's credibility in lawsuits, and may even lead to loss of a medical license.
As such, you should perform chart audits on a monthly or at least on a quarterly basis for criteria such as legibility, completeness, and other factors deemed applicable for your practice and medical specialty. The audits should be performed by clinicians and non-clinicians and results should be discussed. If you are a small medical practice, these audits can be easily outsourced.
Practitioners who have less than ideal audit scores should be notified and given the results of the audit with recommendations for improvement.