Internal Audit in the Department of Medicine of a Community Hospital

The medical audit here described was part of a program intended to evaluate and improve the quality of patient care in a hospital; the immediate question was the quality of the medical records. An auditing committee was formed to assign a numerical grade to each chart. The criteria were the accuracy and completeness of the diagnosis, the adequacy of the treatment, the adequacy of the progress notes, the use of consultation when needed, and the completeness of the physical examination. If a chart was given a mark below a critical level, the physician was notified and given the opportunity to review the chart with the auditing committee. The three members of the committee each had a tenure of three months. The fact that one member began and one ended service each month made it a group project; participation was a valuable experience and not an excessive burden. The medical audit has been effective in improving the medical records of the hospital. Staff members who have been doing good work can see that it is appreciated, and others are stimulated to improve.