Scribe & Chart Audit
Auditing Date (same as working date)
Date
Type of Audit
Please Select
Transition
Implementation
Backup
Quality Audit
Provider
Full Name of Scribe
First Name
Last Name
Name of Evaluator
Please Select
Raghu
Babitha
Muskan Jayaswal
Simranjeet Kaur
Suryadeep Bhattacharjee
Kalgi Pancholi
Javeriya
Manjunath
Shabnam
Amandeep
Thufail
Sanjeev
Madhuri
Mayank
Vipin
Sunyana
Saumya
Reuben
Mudasir
Ritwika
Kanika
Hitesh
Sachin J
Raj Kumar R
Pulkan M
Shalini K
Aastha
Shruti K.
Aman Boora
Atul K.
Oindri M.
Anjali P.
Ashna M.
Yamini K.
Priya D.
Chaishta U.
Trupti B.
Email Address of Evaluator
Chart Number
Please upload a HIPAA compliant image of the chart covering all respective evaluated areas (mandatory).
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Browse Files
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A. English
Please evaluate the presence of English errors (if there are more than five errors, it's a major issue).
Minor Issues
Major issues
All Good
1. Grammar (consists of sentence structure, syntax)
2. Spelling
3. Pronouns
Please share your findings, suggestions, and learning outcome. Type missed information, incorrect information, etc.)
B. Subjective
Please evaluate the following areas of the chart (HPI & ROS).
Minor Issues
Major issues
Critical issues
All Good
1. Captured the visit properly in the HPI without missing pertinent details.
2. HPI well structured (telling a story with proper flow).
3. ROS includes all patient complaints.
Please share your findings, suggestions, and learning outcome. Type missed information, incorrect information, etc.)
C. Objective
Please evaluate the following areas of the chart (PE & A&P).
Minor Issues
Major issues
Critical issues
All Good
1. PE includes all provider findings.
2. Assessment includes all the relevant ICD 10 codes.
3. Plan includes the correct template or the correct plan provided by the provider.
Please share your findings, suggestions, and learning outcome. Type missed information, incorrect information, etc.)
D. Communication
Please evaluate the scribe to provider communication (neutral = no verbal communication, adequate = substantial and pleasant communication, inadequate = lacking rapport and understanding of the provider)
Inadequate
Neutral
Adequate
1. Does the scribe communicate adequately with the provider?
Please share your findings, suggestions, and learning outcome. Type missed information, incorrect information, etc.)
E. Security and Policy Compliance
Please evaluate the scribe's compliance with VPS policies on the production floor.
No
Yes
1. Dual monitor compliance
2. Adequate internet speeds
3. Designated & quiet workspace
4. Power backup
F. Overall Chart and Scribe Quality
How do you rate the overall quality of the chart and scribe?
Poor
Fair
Good
Excellent
Does the workflow adhere to the provider's preference sheet?
Yes
No
Comments.
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