Ensuring physician medical records are accurate

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.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.