Medical Records


This paper focuses on the quality control procedures. The objective of the study was to find a recommendation of quality control procedure in chart audit, to outline possible procedures used in conducting audits, describe a quality improvement model and find out the associations affiliated with improved quality. Quality control is significant for any institution. It involves different procedures and processes. One of the processes that complement quality control is chart audits. Chart audits aim at improving a process. In medicinal institutions, it is mostly done in record keeping with the aim of avoiding errors and other omissions. The chart audit requires procedures for conducting them. There are various procedures to be used. After finding out the areas to improve, a quality improvement model is required to implement the intervention selected. In this paper, secondary data was used to determine the procedures to be used in chart audits. The main sources were websites that are affiliated with improved health care quality control standards. In conclusion, this paper recommends that chart audits be conducted in all medical institutions.

Keywords: chart audit









Quality Control Procedures


Quality control is the course by which a firm evaluates all the processes involved in making a certain pharmaceutical product. It is concerned with reviewing and inspecting the quality of work done. However, quality control does not add worth to the product (Medical coding audits, 2000). The main objective is to identify the product and analyze its purity. It looks at the raw resources used during production. It further looks at all the processes that the product went through. The last stage is testing the product before it is released to the consumers. To implement the process of quality control, medical professional have come up with chart audits. A chart audit is an inspection of medical bookkeeping. The purpose of these audits is to comply with the law and reduce the number of errors and omissions made in a medical environment. On the other hand, it increases the profits and the efficiency of an institution. It measures the quality of different processes in order to facilitate improvement and benefit from the knowledge on the population and the different types of ailments. It is important for a medical institution to come up with the best quality control procedure for completing chart audits.


            Recommendation of quality control procedure in chart audit

The core objective of chart audits is improvement. In response to the task on recommending a quality control procedure, I would recommend the following procedure. The first step is to decide on a subject matter. This step is dependent on the individual in charge. The next step is to recognize the measures to be used. An audit should have an obvious criterion with precise course of action. Thirdly, categorize the patient population. This step is classified in terms of age, sex, the type of ailment under audit and type of cure. For example, if the topic is pregnancy then the population has to be women. The fourth step is to establish the dimension of the sample. A large sample can be misguiding and costly. The next step is to determine the type of tools to be used during the audit. These tools refer to the instruments applied when recording the results. Recording can be done electronically or using paper. The sixth step is the collection of data. The seventh and the eighth steps involve summarizing and assessing the results and implementation

Possible procedures for conducting audits

There are several steps to be followed when conducting an audit. The first step involves choosing a topic. The second step is acknowledging the type of procedures to be applied. Thirdly, categorize the population of the patients then identify the size of the sample to be employed in the chart audit (Patient safety, 2000). The fifth step is to construct the tools to be used in the audit. After all this is done, data is collected. The data is then reviewed and summarized. The last step is analysis. The institution has the opportunity of implementing the results that have been attained from the chart audit (Kaprielian, Gregory, & Sangvai, 2003).

Quality improvement model

Quality improvement refers to the process of finding superior ways of offering health care and services. A good quality improvement model focuses on the objectives for improvement, the measures to be undertaken and the expected changes (Medical reviews, 2004). The use of a team is the best approach to take when dealing with quality improvement. Teams will bring in more than one idea or skill. The FOCUS-PDSA model is effective in quality improvement (American Academy of family physical, 2000). This model uses teams. The team goes through the process of identifying the problem and improving it together. This model has two parts, FOCUS and PDSA. The first part involves establishing the process to be improved such as improving the services given to HIV patients. A team is then put in place to deal with the process. For example, organizing counselors, nurses and specialists for the process. The team then sheds light on the present information about the targeted process (American Academy of family physical, 2000).

The team can use past data collected and literature review. After that, there should be comprehension of the basis for variation and elucidation of the steps involved. Here, a flow chart can be applied to facilitate the understanding of the project. The last step in the first part is to decide on the intervention to apply for improvement. The second part of the model involves preparation for the implementation of the improvement selected. The team begins by planning the strategies to undertake. The plan is put to action. A project analysis is done to find out if there is any change in the process after the improvement. Finally, the team decides on whether to take the actions for improvement. They have a choice of implementing or finding a new process to improve (American family physical, 2000). Medical officer to improve various services in their institution can use the FOCUS-PDSA model. This model works by identifying a process then using a team to plan on how to improve the process (American Academy of family physical, 2000).

 Associations to be affiliated with to keep informed on health care quality standards.

In order to be informed on health care quality standards, this medical practice needs to be affiliated to groups such as:

  • American Academy of Family Physical (AAFP), It is one of the biggest nationwide medical association. Its mission is to make certain that patients receive excellent quality services at a good price (American Academy of family physical, 2000).
  •  National initiative for children’s health care quality (NICHQ), it was established in 1999. Their mission is to ensure that all children be given excellent medical care. In order to achieve this, their main aim is to improve systems.

These institutions have an aim of improving the quality of health services provided to the patients. With this plan, these institutions will keep medical institutions informed.



            Presently, there are numerous complaints about the services and the care provided in health institutions. Chart audits provide a good foundation for record keeping. The chart audits also provide a means by which the institutions improve their services. Records kept in chart audit can also be used for research as a source of data. Through use of chart audits, medical institutions can collect more information about the population that they offer services to and the types of ailments that are prevalent. Before any chart audit is conducted, a proper plan must be drawn (Kaprielian et al, 2003). The plan needs to be centered on an area or a process that needs to be improved. Without a good plan, the chart audit will not serve its purpose. The audits are not only meant for the internal surrounding but also other external institutions or associations.


American family physical. (2000). A team approach to quality improvement. Retrieved from

Kaprielian, V., Gregory, B. & Sangvai, D. (2003). Chart Audits: The how’s and why’s. Retrieved from

Medical coding audits (2006). Medical chart auditing. Retrieved from

Medical reviews (2004). Medical chart audits. Retrieved from

Patient safety. (2000). Quality improvement .Retrieved from


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