Detailed Medical Record Review Questionnaire

This tool provides questions organizations can use when performing a health care audit.

Sample items include: Identifiers are included in records; personal/biographical data includes address, employer and home/work phone numbers; an emergency phone number and contact person are listed in the patient's biographical information; all entries contain the author’s identification; all entries are dated; the record is legible; charts are in good repair and pages are fastened to the file; there is a standardization of filing within the chart; and health maintenance, significant illnesses and medical conditions are listed on a problems list.