Please take the time and read these entire instructions. I have also put them in a word document which is attached. Feel free to print the document and review it as you complete the audit report.
You have been asked by the HIM director to review 20 charts for compliance with the New York State Department of Health (DOH) standards for health care facilities. After you complete your review it will be presented to the Board as a Compliance Study. In this assignment you will be reviewing the chart audit tool created by Information Systems which abstracted data from the medical record for state standard compliance.
/content/enforced/1154391-SPS01_HIM_351_1262_1_44190/Competency Audit Instructions in word document format January of 20265 CUNY1.docx
/content/enforced/1154391-SPS01_HIM_351_1262_1_44190/Completed Tool for Audit competency project Jan 20261.xlsx
Here are the steps to accomplish:
1. Review the New York State standards just so you are familiar with them. You can copy and paste this URL into your browser. : https://govt.westlaw.com/nycrr/Document/I4ffd11dccd1711dda432a117e6e0f345?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)
2. Use the attached completed audit by Information System to determine compliance with the above regulations. Normally you would pull up each chart and review the chart to see what elements are missing but Information System has done that for you.
3. The EMR was used for the audit. If this was a true audit, 20 records would not be acceptable because it is too small of a sample to be statistically significant but this is just an exercise. For future reference when conducting an audit you would use 5 % of your monthly volume.
4. Once you review the compliance with the standards, create a written report that will be presented to the Board of Trustees to summarize these findings and make measurable recommendations for how to improve compliance. This report should be a minimum of 2 pages identifying compliance and non-compliance. It usually has a brief overview for the Board which explains why the audit was done and what it is supposed to accomplish. = 40 points
5. To enhance your written report, it is usually helpful for the audience to see graphs. This usually keeps the reader’s attention. Be sure to use meaningful graphs of compliance and non-compliance documented on the tool compared to the NY regulations. = 21 points
6. Create a flow chart on how you would have performed the audit from beginning to end. 21 points
Below are the key steps in a medical record documentation audit, from requesting an IT report to final recommendations. Each step includes critical decisions and actions, based on best practices and audit templates
Create a Flow Chart using correct Flow chart symbols.
text
flowchart TD
A([Start]) –> B[Request Report from IT]
B –> C[Review line items for each record in the Audit]
C –> D[Are all documentation line items complete/present? ]
D –> Yes—-> E [Mark complete and continue forward to F]
E –> No —-> F [Document Deficiency]
F –> G{Are there more items to review?}
G — Yes –> H[Review line items and continue to back to C ]
H — No –> I[Summarize findings]
I –> J[Create report]
J –> K ([End])
Flow Chart Symbol Key
Symbol
Shape
Meaning
Terminator
Oval
Start/End of process
Process
Rectangle
Action step (e.g., review, retrieve, create)
Decision
Diamond
Yes/No or branching point
Document
Rectangle with wavy base
Represents a document/report
Arrow
Line
Flow direction
