This feature is currently in limited release to a select group of clients and will be rolling out to everyone in the coming months.
Note Audit helps assess whether documentation meets required criteria by showing which elements are complete and which still need attention.
Required permissions: Permissions to run Note Audit depend on the evaluation status:
- Open (unsigned) evaluations: Users with Note Audit: Create
- Signed evaluations: Super Admins or Records Admins with Note Audit: Create
Click here for instructions on assigning Note Audit roles.
Using Note Audit
Once you’ve configured an evaluation template with Note Audit rules, add the evaluation to the patient’s chart and complete the note as you normally would. When you’re ready, click Run Note Audit.
Step 1: Run Note Audit
When an evaluation includes Note Audit rules, you can click Run Note Audit. Depending on the number of rules and the length of the document, the report may take some time to generate.
- The button will be grayed out if Note Audit rules are not configured.
Step 2: Review the Audit Results
After you run Note Audit, the system generates a report that includes:
Audit Score: A percentage score (out of 100%) based on completed elements and the weights assigned during rule configuration.
To-Dos: A list of required elements that still need to be completed.
Completed Items: A list of requirements that have already been satisfied, including where they were documented.
3. Address To-Dos and Re-Run the Audit
Use the audit results to complete any remaining required items:
The To-Dos tab shows all incomplete items and the total number outstanding.
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The Completed tab shows:
How many items meet the compliance rules.
Hover over the Documented in [location] text to show the justification for why this item is marked as completed.
- Click the Documented in [location] text to open the part of the note where that field can be found.
When additional items are completed, click Evaluate to re-run the audit and update the score.
Feedback
We encourage you to provide feedback for the entire report and/or for individual items.
The steps for creating positive and negative feedback are the same regardless of whether you're leaving feedback for individual items or for an entire section.
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- To leave positive feedback, click the thumbs up icon. To add more context, click Tell Us More.
- Select the options that apply, and (if needed) provide additional comments or context in the text box. Then click Submit.
- To leave positive feedback, click the thumbs up icon. To add more context, click Tell Us More.
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- To leave negative feedback, click the thumbs down icon. To add more context, click Tell Us More.
- Select the options that apply, and (if needed) provide additional comments or context in the text box. Then click Submit.
- To leave negative feedback, click the thumbs down icon. To add more context, click Tell Us More.
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