5.  PERFORMING A MANUAL AUDIT

c. Completing the Audit Form

Manual auditors may obtain a 2008 audit form here.  Using the instructions that follow, review the medical record to see if each of the indicators are satisfied. If you cannot find a result in the chart, then for the purposes of the audit, apply the old dictum,

"If it is not documented, it did not happen."

Finally, please remember that all medical records are confidential documents and need to be handled accordingly.