Medical Auditing Practice Exam

What should an auditor do when chart entries are signed in the EMR three days after patient visits?

1. Ignore the findings

2. Prepare a summary of findings with recommendations

3. Advise immediate termination of the provider

4. Implement penalties for late charting

The correct answer is: Prepare a summary of findings with recommendations

Preparing a summary of findings with recommendations is an essential step in addressing late chart entries in the electronic medical record (EMR). When an auditor notices that chart entries are signed three days after patient visits, it becomes crucial to assess the potential implications of this delay on healthcare quality, continuity of care, and compliance with regulations. Late documentation can signify inadequacies in the workflow, potential issues with patient safety, or even non-compliance with regulatory standards regarding timely medical recordkeeping. By compiling a summary of findings, the auditor not only highlights the issue but also provides context on how it affects both patient care and the practice’s operation. Additionally, including recommendations allows for constructive feedback and guidance on improving documentation practices. This might involve suggesting training, revising workflows for efficiency, or implementing a monitoring system to encourage timely entries. This approach promotes a proactive means of problem-solving rather than punitive measures, fostering a culture of improvement within the healthcare setting. In contrast, ignoring the findings would overlook significant issues that could impact patient safety and legal compliance. Advising immediate termination of the provider or implementing penalties for late charting may create a hostile environment without addressing the root causes of the problem or allowing for corrective actions.