We developed an original audit form our medical record in order to rationalize our work. The study examined the effectiveness of this form.
The medical records to be audited were randomly selected for one patient per therapist. Audits were conducted approximately every 4 months from December 2022 to May 2024. The audit form consists of twenty-three items in seven domains. Domain 1: description of the medical records based on the SOAP format, domain 2: preparation for the planning of a comprehensive rehabilitation, domain 3: description of the latest information, domain 4: ethical considerations, domain 5: practice of periodic evaluation, domain 6: guidance on rehabilitation at discharge, and domain 7: preparation of a medical information form to other hospitals. Seven chief therapists served as auditors, and scored each item on a scale of 0 to 2.0. After scoring, advice from the auditor to each therapist. The Friedman test was used for statistical analysis.
The medical records of 33 therapists were routinely audited five times within this period. Therapists' ages ranges from 24 to 55(M=34.1). The Friedman test resulted in significant improvements between the first vs. the second, third, fourth and fifth audits in the overall score (P0.01), the first vs. the third audit in domain 2 (P0.05), and the first vs. the third and fourth audits in domain 6 and 7 (P0.05).
The repeated medical record audits using our original form improved the quality of description by each therapist. The improvement was clear especially in domain 2, 6 and 7 after audit. It may suggest that at least three times of auditing results feedback is necessary to improve the content quality.
Our original audit form for therapists’ medical records was useful. Repeated feedback of auditing results to each of therapists helps them to improve the content quality and to practice team medical care.
therapists
audit form
