Medical Record Audit Form
Patient MR# ____________
Sex___________
Age _______ Procedure Date ______________
Procedure ______________
Y = Yes
Physician ___________________
N = No
N/A= Not Applicable
Administration
Advance Directive Y or N, if Yes or No a copy in chart or patient did not bring
Signed acknowledgment of PT rights
Pre-Op
Operative consent signed and witnessed.
Allergies documented in pre-op Phone call. Record, Orders, and Med Rec
Pre-op orders signed, dated and timed
Laterality and type of anesthesia marked on orders
Height and Weight documented on pre-op record
If HVG box checked, a result noted on record
If a blood glucose performed the time is was performed is documented
If patient has an IV, it is documented they have a hep lock or fluid, and an order
If IV fluid ordered, documented rate, and amount patient received in Pre-op
All medications given have an order
Medication route and time completed
Peri-Operative
Documentation of “time out” procedure
Allergies documented on Operative record
Procedure performed laterality marked on operative record
Surgery check list complete
Pain level assessed and documented.
Use of approved abbreviations only.
Operative record includes procedure, prep, pre-op dx and post procedure dx
Operative report note dictated, transcribed and signed
Operative record indicates times for start, finish, and out of room
PACU
Vital signs taken upon admission to PACU
Vital signs taken every 15 minutes x 2 and every 30 minutes until discharge
Vital signs documented within 10 minutes of discharge
Med Rec form completed, eye drops present, added prescriptions present
Discharge order is timed after case finish time on operative record
Discharge instructions given and documented
Documented patient fluids and denial of N&V
Patient met discharge criteria
Discharge medication addressed including any RX and documented on Med Rec form
with how prescribed (paper vs called in)
Patient discharge with an adult and documented, except for YAGs as applicable (verify
order for no driver on YAGs)
Anesthesia
Anesthesiologist pre-op evaluation immediately prior to surgery noted.
Anesthesia record complete.
Required signatures of MD and CRNA present, and dated.
Discharge note present. Post-op assessment present and timed
Post-op Phone Call
Post-op phone call complete
All issue documented
Follow up documented
Medical Record Reviewer Initials: ____________
Date: ____________
Action:_____________________________________________________________________________________________
Follow-up: __________________________________________________________________________________________