Medical Record Audit Form
Please fill out the following form to perform a medical record audit.
Name of the Healthcare Facility
Name of the Auditor
First Name
Last Name
Date of the Audit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
First Name
Last Name
Patient ID
Was the patient's demographic information correctly recorded?
Yes
No
Was the patient's medical history documented?
Yes
No
Were all the prescribed medications properly recorded?
Yes
No
Was the progress note comprehensive and up-to-date?
Yes
No
Was the privacy and security of the patient's information maintained?
Yes
No
Additional Comments
Auditor Signature
Submit
Should be Empty: