Medical directors are responsible for chart audits and sharing results with staff

A patient’s medical record is a single comprehensive file containing all information and documentation related to the patient’s surgical encounter including medical history, physical exam and a surgeon’s consultation outlining the indication(s) for surgery.

To ensure that the medical record provides an accurate and comprehensive account of the care provided to each patient, medical directors are required to have a chart auditing process in place. In addition, medical directors are responsible for ensuring chart auditing results are shared with their staff and any required actions are implemented and maintained.  

To access the Non-Hospital Medical and Surgical Facilities Accreditation Program (NHMSFAP) accreditation standard Medical Records and Documentation and other NHMSFAP accreditation standards, click here.