Audit Process for Scan

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Auditor

Practice Supervisor/Medical Records Supervisor/Centralized Scan Personnel will perform the audits, completing the “Audit Performed” documentation and forward those documents to the Practice Administrator or defined person within 24 hours of completion via secured email.

Frequency

  • Weekly Audits until 90% accuracy or higher is obtained
  • Then Monthly Audits until 100% accuracy is obtained
  • Then Quarterly Audits
  • IF at any time accuracy drops down to below 90% weekly audits will be renewed

Chart Audits

  • 20 charts per provider per week until 80% accuracy obtained
  • Then 10 charts per provider per frequency stated above thereafter
  • 5 (2 once 80% accuracy benchmark has been reached) charts per provider, per day will be selected from the schedule
  • Visit types should be varying, i.e.: New Patient, Consult, Follow Up, etc.
  • Auditor should track the number of errors by user

Go Forward Document Audits

  • Current Document’s scanned will be stored in pendaflex folders, labeled each day of the week scanning occurs

Once the audit is performed, these documents can be filed/disposed of according to policy

  • Batch Basket Audits should be completed at the following frequency rates
    • Daily until 80% of the expectation is reached
    • Weekly until 90% of the expectation is reached
    • Monthly thereafter
  • All batches are to be sorted within 3 days.
  • Report should demonstrate the number of batches less than 3 days and the number of batches greater than 3 days.

Content Audited

Documents scanned will be audited for:

  • Is the document in the correct patient’s record?
  • (Include any special internal policies, such as blacking out the SS#)
  • Resolution – is the document readable?
  • Was it scanned into the correct folder?
  • Is the document scanned in the correct orientation? I.e.: Was it scanned upside down?
  • If a current document was the correct date and provider assigned to the document
  • Timeliness of scanning

Determine, by following your current process, what a reasonable/acceptable amount of time is from the time the document was received until it is scanned. (Set the Expectation)

Remedy

This will need to be addressed by administration prior to Scan Go Live. What action will be taken when the above audits are not completed? What action will be taken when an audit fails?

  • If a document fails the audit it will be retrieved either from the pendaflex folder or the patient chart and rescanned
  • Audit logs will be viewed, on failed audits, for follow up training purposes
  • If an ongoing issue is not resolved – administration and/or Practice Manager may take disciplinary action
  • Failures to meet Benchmark will be reported at the Board meeting
  • Accuracy issues will be reported to the Board
  • User Patterns and trends will be monitored when a pattern or trend is recognized the following actions will be taken:
    • Retrain
    • Removed from Scan

Additional Scan Recommendations

  • Keep a log, per stager, how many charts were prepped each day
  • Create a baseline with your most proficient stager
  • Keep a log, per scanner, how many charts were scanned each day
  • Create a baseline with your most proficient scanner
  • Track the number of charts scanned
  • Set Goals and Rewards when goals reached when milestones are reached
  • Train providers and staff how to task a document that requires attention, those that:
    • Are in the wrong patient chart
    • Poor Resolution
    • Scanned upside down or sideways
    • In wrong folder