Appendix D: Chart Audit Checklist

Appendix D
Chart Audit Checklist


  1. Billed services are documented (X-ray, PT, rehab)

  2. Special studies performed include explanation of why the test is necessary and a description of the impact the test(s) had on treatment &/or diagnostic decisions 

  3. Diagnosis made is supported by the findings of the case

  4. Legibility

  5. List risk factors of a prolonged recovery ( See Appendix C)

    • Conditions diabetes, cardiovascular disease, CNS disorders, medication interactions, etc.

    • Yellow flags (depression, anxiety, poor coping strategies, fear avoidant behavior, job dissatisfaction, etc.)

  6. Treatment Plan - included? Followed?

  7. Periodic recheck and updated treatment plan. Followed?

  8. Exacerbations affect recovery? Home vs. work?

  9. Were work restrictions/modifications issued? Followed?

  10. Outcomes oriented documentation

  11. Goal oriented management

  12. Use of the Appeal process

  13. Reasons for care denial

      1. Insurance letter/opinion

      2. Based on consultant file review (MD vs. DC vs. "anonymous"; qualifications included?)

      3. Based on IME

      4. Guidelines cited

      5. Records reviewed listed?

  14. MMI reached? If so, when? If not, any predictions or special tests needed before MMI is reached?

  15. Treatment effectiveness

  16. Pertinent past history findings (list & describe impact to the current case)

  17. Rehabilitation (progression from passive to active care)

      1. Anything more than "exercises given" listed? How frequently? Any follow-up? Any objective physical testing pre-/post-rehab to document outcomes?

      2. If multiple units (each 15 minutes) - is this clearly documented (what was performed, SOAP approach for rehab service, "scorecard" of performance, etc.)

  18. Was each page signed & dated?

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