You are the HIM Director at Acme Hospital a 300 bed facility. Acme specializes in cardiac care and treats approximately 750 patients a month. You have been tasked with designing a chart audit tool to show compliance with these standards. Select 10 standards that you feel are important to illustrate compliance with documentation within the medical record. This chart audit tool (form) should act as a data collection tool for analysis of compliance. Some things to think about while you are designing your form: What patient identifiers will you include? While meeting ALL of the standards is important, what 10 do you think are the most important?

Once you have designed your form, write a brief paragraph about your audit plan. Who will perform this audit? How many charts will be audited? How often will the audit be performed? Will the form need to be adapted for specific units? Such as pediatrics and newborns? If so, what would you suggest for these units? If not, why not?