Chart Result

The Chart Result section highlights documentation and coding elements that apply to the entire patient encounter. Auditors can review key items such as patient consents, signatures, and overall chart completeness. In this section, users can also identify relevant Errors, complete chart-level Checklists, assign a Master Outcome, and add custom comments. A summary of possible points, deductions, and the resulting accuracy percentage gives a clear picture of the overall performance for each auditee claim.

Follow these steps to add details for the Chart Result.

• Click on the individual tabs to add relevant information:
  • Checklists – Select applicable chart-level criteria.
  • Master Outcome – Choose an appropriate outcome based on documentation.
  • Errors – Identify and record any chart-level errors.
• Once all the required details are added, the Result Summary table automatically calculates and displays the Accuracy Rate.
  • • Line refers to findings at the individual data element (line item) level.
    • Chart reflects observations related to the overall patient chart, such as documentation completeness or missing signatures.
    • Total combines the results from both Line and Chart levels to give a full picture of audit performance.
  • Possible Points – The maximum number of points that could be earned if everything were correct.
  • Deduction Points – The points lost due to errors in documentation or coding.
  • Accuracy Rate – The percentage of accuracy, calculated using the formula:
    (Possible Points - Deduction Points) ÷ Possible Points × 100
• To add additional information for a specific data element, click the Custom Comment link. After entering your comment, select Close Comment to hide the comment box.
• After finishing all selections in the Chart Result section, users can scroll down to the Audit Result section to proceed and complete the remaining steps of the audit process.