Individual Audit Stream

This Audit Stream is for residents NOT in the following Family Medical Centres

• Victoria Family Medical Centre

• St. Joseph's Family Medical & Dental Centre

• Byron Family Medical Centre

• Southwest Middlesex Health Centre (Mount Brydges)

• Middlesex Centre Family Medicine Clinic (Ilderton)

• West Middlesex Health Centre (Strathroy)

All of our Family Medicine residents are required to participate in AT LEAST ONE CHART AUDIT SESSION IN EACH OF THEIR 16 WEEK FAMILY MEDICINE BLOCKS.  Chart audits look at the quality of care through reviewing the documentation in a patient’s chart and are based on the CPSO’s audit form.  When in your own practice, you will be required to do a self-audit as part of a mandatory QI CPSO exercise (currently every 5 years) or may even be subjected to a CPSO practice audit for various reasons.  The guidelines for appropriate medical documentation can be found on the CPSO website under:  “CPSO policy for Medical Records”.  These can be found by using the Google search terms “cpso medical record policy” or from the "Resources" section on this site.

There are 3 audit periods

• April, August and November

STEPS for Doing an INDIVIDUAL CHART AUDIT

1. Please discuss with your preceptor about doing a chart audit.  Ask them for their permission.  If this is okay, then please proceed to the next step.  If not, please contact the Chair of the Records & Quality of Care Committee using the email address in the "Support" section of this site.

2. The chart audit process will take you about 1 hour to complete.  To do the chart audit, you must randomly pick a minimum of 3 charts and use a separate audit tool for each chart.  You will need to print at least 3 copies of the chart audit tool that is attached below.

3. The next step is to do the chart audit.  A few tips are listed in the chart audit tool.  Otherwise, the chart audit tool should be self-explanatory.

4. Once you have completed your chart audits, review each question from each of the audit tools to look for trends.

5. Review these findings with your preceptor and/or team.  Think about how you may make changes to improve the documentation in this practice.  

6. Destroy (i.e. shred) the audit tools once the exercise has been completed.

7. Log your participation for this doing this chart audit in your online academic credit reporting system.

If you have any questions, please contact the Chair of the Records and Quality of Care Committee form the "Support" section of the site.

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