Fall Reset: 5 tips to make auditing medical records a habit

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Consistent, complete, and well-organized medical records are essential for any veterinary practice, and have a wide range of benefits. Reviewing medical records reveals lost or incorrect fee charges, changes in doctor productivity, quality of patient care, and even the overall culture of your hospital. Integrating a regular auditing process can seem like an impossible task in the hectic hospital environment, but we have some tips to make it a seamless and painless part of your management routine.

1. Set aside a regular time

Auditing your records frequently and consistently is the best way to ensure that you stay on top of them. Medical records should be audited daily or weekly, and at least monthly at most practices. Set aside a short and manageable amount of time each day or week that can be devoted just to reviewing medical records. Put it on your calendar today for the quarter or entire year ahead, block off the time in your busy schedule, and make a commitment to stick to it.

2. Make it a positive routine

Once you’ve settled on the frequency and time, incentivize yourself by picking a positive reward that you can only have during an audit. Bestselling author and habits expert Gretchen Rubin calls this the Strategy of Pairing, and it can help you to turn a dreaded task into a beloved and regular habit. Enjoying a snack, your favorite drink, or putting in headphones to listen to an album or podcast can help you look forward to an otherwise tedious audit.

3. Have the right tools

Do you have a checklist of items to review for each medical record? Are your current medical records helping your practice adhere to the AAHA Standards of Accreditation? If not, consider seeking out resources that can help. Practice Made Perfect by Marsha Heinke, DVM, EA, CPA, CVPM, includes a comprehensive guide to medical record auditing, and AAHA’s medical forms and records ensure that auditing is easy and that your practice is upholding AAHA’s medical recommendations.

4. Designate a rotation of helpers

Practice managers are the ideal people to audit medical records, but they shouldn’t be the only staff member trained and equipped to handle the task. Designate a rotation of doctors, lead technicians, and other appropriate staff to lend a hand with auditing. Distributing the task ensures that medical record auditing can continue when you are out of the office and also presents a perfect teaching opportunity for you and your team.

 5. Spot check for efficiency

Don’t spend your valuable and limited time reviewing every single medical record in your practice. Reduce the workload by establishing a regular rotation of what you’ll review. Select two or three records from each doctor in your practice to give you a snapshot of the overall state of their medical records. Be sure to rotate the type of record you review as well. One week can be devoted to wellness exams, followed by surgical records, and so on.  

Each patient’s medical record tells a story—not just about the pet, but also of the quality of care provided and the overall culture of your practice. When you are routinely auditing and correcting them, you can be confident that you are practicing excellent medicine, maximizing profits, and growing and improving as a team.

About the author

Judy Rose Lanier, CVPM, CVA, has worked in veterinary medicine for more than 20 years. Her position as a practice consultant and regional manager for AAHA provides her with wonderful opportunities to raise the level of care for patients and clients, promote continual learning, and improve the quality of life and job satisfaction of those working in the veterinary field.

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