No one has time to review every chart. Yet quality assurance depends on knowing whether documentation is complete, care plans are followed and processes work as intended. Sampling is the practical answer: reviewing a carefully chosen subset of records on a regular schedule. Done well, it gives leaders a reliable picture of how the building is doing without overwhelming the team. This post offers a general approach for quality audits using your electronic health record, including PointClickCare. Available reports and tools vary, so check with your administrator about what your configuration supports.
A sampling audit asks a focused question about a process, for example: "Are admission assessments completed on time?" or "Do care plans reflect recent changes in condition?" It is not meant to catch individuals out. It aims to find patterns that point to a process or training need, and to confirm that improvements are working.
Start with a narrow, specific topic. Good candidates include:
Timeliness of admission assessments and care plan updates.
Completeness of fall risk or skin assessments.
Documentation after a change in condition.
Medication administration documentation and follow-up on refusals.
Consent and advance directive documentation.
Documentation of notifications to physicians and families.
Pick topics based on risk, survey findings, incident trends and leadership concerns. Rotate them through the year.
Before reviewing, write down what "good" looks like for each question. Use a short checklist with yes, no or not applicable answers, tied to your policies and regulatory expectations. The same checklist should be used by every reviewer, so results are comparable. Keep it to a manageable number of items, since long checklists lead to fatigue and sloppy answers.
How you choose records matters, because a biased sample gives misleading results.
Avoid hand-picking charts. Use a simple random method, such as assigning numbers to the eligible residents and using a random number generator in a spreadsheet to pick. If your record system can produce a list of eligible residents, export it and sort it randomly.
For a small building, reviewing a fixed number of charts per month, perhaps five to ten, can be enough to see trends. Larger populations or higher-risk topics might call for more. Statistical precision is less important than consistency. The same approach each time makes trends meaningful.
Make sure the sample draws from different units, shifts, payers and lengths of stay, if relevant, so you do not miss problem areas. Include recent admissions and long-stay residents where the topic applies.
Assign trained reviewers, such as nurse managers, MDS staff or quality nurses, who do not review their own work when possible.
Review within a defined window, and record the findings in a standard form or spreadsheet.
Capture notes on what was missing or unclear, not just the score.
Maintain confidentiality. Use only the information needed, and store results securely.
Make sure the reviewer is accessing records in line with their role. Audits are a legitimate purpose, but access should still be limited and appropriately logged.
Calculate the percentage of records that met each standard, and track them over time. Look for patterns by unit, shift, document type or staff group. A single low result is not necessarily a trend, but three months of the same gap is. Share the results in aggregate in your quality assurance meetings.
For each significant gap, decide what to do: re-educate staff, adjust a template or workflow, clarify a policy, change a reminder or provide extra support to a unit. Assign an owner and a date. Then sample again later to see whether the change worked. This loop of measure, act and remeasure is the heart of quality improvement.
Give positive feedback, too. Highlighting areas where the team is doing well builds trust and shows that audits are about improvement.
Auditing too many topics at once. Focus produces better results.
Changing the checklist constantly, which makes trends meaningless.
Treating audits as punishment, which discourages honest documentation.
Not following up. Findings without action waste everyone's time.
Poor record-keeping. Keep evidence of the audits and what was done in response, since it supports your quality program.
Ask whether your record system can generate lists of eligible records, flag missing items or produce summary reports. A simple spreadsheet can handle the sample list, checklist and charts. Automating routine pieces leaves more time for reviewing and improving.
UnityCare IT helps long-term care teams set up reports, secure shared audit tools and the access controls that keep reviews appropriate. If your audits take more manual effort than they should, we can help streamline them.
Keeping PointClickCare and other EHR systems fast, connected and available.
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