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Clinical File Audits

Denise Gardner 3 years ago in Clinical Charting Module updated by Celia 2 years ago 8

What types of internal file audits are agencies doing and how are you using functions in Procentive to make the process efficient? We used to have a staff look at each clinical file and review for timeliness and content. I am hoping there are systems in Procentive already to help with this or if we need to request something be created? Any ideas would be great!

Denise,

We are actually going through the same thing right now. Currently we have staff checking clinical files one by one. I have been working with the Quality Improvement Coordinator to see what the best way would be to get our checklists into Procentive.

I would also be interested in whether there are processes or suggestions for how to make this go more smoothly. We currently use workflow triggers for some notifications for creation/signatures on certain forms to determine timeliness which does help however to review charts continues to be a one at a time process that is time consuming, tedious, and at times frustrating.

I have been compiling a list of items we would like to pull for file audits that I need to get sent to the Quality Improvement Coordinator. It might be good to compare our file audit lists to see if this is something that would benefit all of us. What I don't know is do we share our lists here or exchange emails? We have several workflow rules associated to documents cuing each participant in the clinical review and approval of the document, cuing signatures in order of need (i.e. ITP approved, then guardian signature, then mental health practitioner signature and then mental health professional signature) and notifications to complete documents. I created workflow rules for all of our forms to be cued by staff marking the document audit ready. However the process doesn't go smoothly and there are documents throughout the files that haven't been finished to the end of the process including missing signatures and other steps.

For the organization I work for we have several different programs we use Procentive for. Each program has their own checklist based on the outcomes that are done quarterly. I recently asked Procentive if it were possible to have data flow into these checklists so we wouldn't have to manually enter it client/form individually. They are hoping that in the next version, 2.0, that this could be a possibility.. It sounds like a few other organizations are asking the same thing.

Yes, that would be wonderful. That process is very time consuming when the data is just sitting there in the system. We have created some raw data reports that pull information from specific forms but this only pulls raw data off of one form at a time and can also be difficult to deal with since it is in raw spreadsheet form and is dependent on a lot of factors.

Our forms and the process we use is very specific to our forms, contracts, and services such as items required by certain payers to be present or for MN vs ND programs etc. and I don't know that the actual form itself would be particularly helpful to you but I'm interested in your process of trying to get it done through Procentive. In the end, I need my clinical supervisors to have a hands on look at documentation for content and a process for recording their observations and feedback which I don't know can be automated other than by providing the list of charts to review on a regular basis. But I also want to check off whether certain documents are present and whether they are signed and whether they were entered into the record and completed/signed in a timely manner all of which I believe could be pulled using Procentive reports. One single report that pulls all of that into a format that is easily communicated to the staff members who need to know or fix errors would be extremely helpful to me. Right now we do it fairly peace meal and as you noted, it's not very efficient or consistent and if a document gets stopped in the workflow because someone didn't sign it, I don't have the workflow set up properly to alert anyone to that fact. That type of workflow is complex and difficult to set up so that it functions the way we want it to.

Here is my email if we decide to share sgile@fccnetwork.org

I happened to come across this conversation and would like to inquire whether you were able to create a more simplified way of auditing charts?  We were in between full electronic and hard copy charts, so I was procrastinating, but now we are full EHR.  I am interested in what you have created or found to be unhelpful.  Thank you!