Introduction to and Background of Clinical Audits

Doctor completing medical ecordThe clinical audit is a process that is designed to improve the quality of data recording in medical practices. The task involves the reviewing of healthcare delivery to make sure that the best practices are being used. Because the records that a practice keeps are a reflection of the quality of medical care that is delivered, clinical audits always start with the paperwork.

The clinical audit is an established part of the healthcare landscape, making it a possible key component of clinical governance in the future. Recently, there has been a move away from optional clinical audits, as a more “required” approach has been taken by some. A good example of this is the Community Pharmacists. In 2005, clinical audits were a contractual obligation for them. Now they are becoming a contractual obligation for even more healthcare providers, depending on their exact function. Healthcare professionals are now expected to participate in clinical audits and, in time, these audits will be a key quality improvement activity for the revalidation of doctors.

The Mixed Reputation of Clinical Audits

The reputation of clinical audits is quite mixed in that some say that the clinical audit is falling short of its potential, causing a need for it to be restructured. This really depends on how it is conducted and the results utilized.

Since 2008, the Department of Health, has secured great amounts of funding for the development of more sound clinical audits. There are now a number of National Clinical Audits. The drivers for clinical audits have grown at very fast rates.

Conducting Your Own Audit

While there are times that governing agencies may request an audit to ensure the soundness of procedures happening within the practice, particularly in the realm of Medicare and Medicaid, you can do your own.

It is ideal to have a third party conduct a clinical audit of their own to determine the soundness of procedures. When you audit medical records, errors can be found, brought to the attention of those that need to know about them, and a plan put in place to correct those errors. Audits are also a very important part of fraud prevention.

When you conduct your own clinical audits, you are able to catch errors that could prompt audits from other entities. Also, avoiding fraud is going to benefit your practice a great deal. Fraud prevention means avoiding fines that could be imposed if the fraud is found to be the fault of the practice.

What to do with the Results

So exactly what do you do with the results of a clinical audit? Evaluate them. Evaluate the results and implement all of the suggested changes. Rather than trying to see everything from where you are standing every single day, the audit enables you to follow a list of changes. You can check them off of your list as you make the changes and then go back and check again to make sure the changes are being implemented. If a change is not being implemented, then you can provide the necessary guidance on the issue that needs addressed.

To make this process more efficient, one person can be designated to oversee the changes. This can make changes more efficient and organized so that regular operations within the practice or facility do not suffer.

All in all, the audit and the implementation of changes are things that can be handled. They may seem overwhelming at first, but, as stated earlier, professional assistance is something that can make a significant difference within your practice. There are consultants that are trained to help you every step of the way so that everything is sound. When everything is sound, then you will be able to improve such areas as charge capture and better care overall. You can also avoid costly fines and consequences for alleged fraud or eliminate any fraud that may be occurring within the practice that you may not know about. It is a move that pays off again and again in the end. However, keep in mind that one audit is not enough. You will want to conduct audits periodically to ensure no new issues have come about, no old ones have been allowed to persist, and no old ones have reappeared. That way if something such as a Medicare audit comes about later on, you are prepared.


When you want to audit medical records or other areas of your practice, it is good to have medical consultants by your side every step of the way. At MD Pro Solutions, we help you with your audits so that you can get the most out of them. Call us at 508-946-1665 or complete our contact form for more information.