Audit tool

Outpatient record audit: JCI standards for documentation quality (international)

An audit tool for outpatient records, checking documentation quality against JCI standards for patient identification, assessment, diagnosis, treatment, and follow-up.

Fill it in online - free, no account needed. 42 questions.

What it is for

This template provides a structured audit for assessing the quality of outpatient medical record documentation.

The full question list

1. Record Identification and Patient Information

  1. The patient's full name is present on every page of the record. *
  2. The patient's unique identifier is present on every page of the record. *
  3. The patient's date of birth is recorded in a dedicated field or clearly labelled section. *
  4. The record contains a documented date of last verification for patient contact information (e.g., address, phone number). *
  5. Patient contact information includes at least one current phone number and a residential address. *

2. Clinical Assessment and Diagnosis

  1. The patient's chief complaint or reason for visit is documented. *
  2. The patient's chief complaint or reason for visit is documented at the beginning of the encounter note. *
  3. A history of present illness is recorded. *
  4. The recorded history of present illness includes the duration of symptoms. *
  5. The recorded history of present illness includes the severity of symptoms. *
  6. Past medical history includes documented conditions relevant to the chief complaint (e.g., diabetes for foot pain, asthma for cough). *
  7. The documented physical examination includes findings directly related to the chief complaint (e.g., lung auscultation for cough, joint examination for pain). *
  8. A provisional or definitive diagnosis is clearly stated. *
  9. The diagnosis is stated using standard medical terminology. *
  10. The diagnosis is supported by documented clinical findings. *

3. Treatment Plan and Medications

  1. The treatment plan is documented. *
  2. The documented treatment plan directly addresses the stated diagnosis. *
  3. All current prescription medications are listed. *
  4. All current over-the-counter medications are listed. *
  5. Dosage is listed for all current medications. *
  6. Frequency is listed for all current medications. *
  7. Known allergies are recorded in a dedicated, clearly visible section (e.g., allergy band, specific section in EHR). *
  8. Known adverse drug reactions are recorded in a dedicated, clearly visible section (e.g., allergy band, specific section in EHR). *
  9. Patient education regarding the treatment plan is documented.
  10. Patient education regarding medications is documented.

4. Documentation Standards

  1. Every entry in the record is dated. *
  2. Every entry in the record is timed. *
  3. Every entry in the record is signed by the author. *
  4. Number of unapproved abbreviations found in the record (compared to the facility's approved list). *
  5. Handwritten documentation is readable without ambiguity. *
  6. Documentation is free from vague or ambiguous statements that could lead to misinterpretation. *

5. Results and Follow-up

  1. All diagnostic test results (e.g., lab, imaging) are present in the record. *
  2. There is documented evidence that diagnostic test results have been reviewed by a clinician. *
  3. Documentation of actions based on diagnostic test results indicates a clear plan for patient care. *
  4. Follow-up appointments are documented with a specific date and time or a clear timeframe for scheduling. *
  5. Follow-up appointments are documented. *
  6. Referrals are documented with the name of the referred specialist/service and the reason for referral. *
  7. Referrals are documented. *
  8. Instructions for the patient regarding follow-up care are documented with specific, actionable advice.

6. Sign-off

  1. Name of person completing this audit *
  2. Date and time of completion *
  3. Signature of auditor *

References

How the score works

The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.

Questions

What does this audit cover?

This audit covers key aspects of outpatient record documentation, including patient identification, clinical assessment, diagnosis, treatment plans, medication lists, and follow-up arrangements, all aligned with JCI standards.

How often should this audit be conducted?

The frequency of this audit depends on your facility's internal quality assurance policies and JCI accreditation requirements. Regular audits are recommended to maintain high standards of documentation.