4.  MANUAL CHART REVIEW vs. 'ELECTRONIC' (RPMS) AUDITING

As mentioned in the introduction, for any given patient, information on diabetes care elements and outcome measures may be gathered in one of two ways: either by sitting down and physically reviewing the medical record (a “manual audit”), or by performing a computerized review using RPMS’ Diabetes Management module (an “electronic audit”).  A few sites use non-RPMS software to conduct their e-audits.

There are pros and cons to both the manual and electronic audits.  The manual chart review is more time consuming and is subject to both the benefits and liabilities of requiring human judgment during the audit process.  The electronic audit is much quicker, although it requires time and attention to careful set up before the first audit can be run.  E-audits are independent of human judgment since determinations are made by internally programmed computer logic and are therefore more consistent than manual audits. Their accuracy is more subject to proper PCC documentation, coding and data entry issues. 

More and more facilities are opting to perform e-audits due to the time savings and ease of performing regular periodic audits once the initial setup has been completed.  We encourage the use of electronic audits whenever feasible. 

For facilities wishing to transition from a manual to an electronic audit, it is imperative that they initially run simultaneous manual and e-audits to compare the results.  In theory, the results from the manual and e-audit should be quite similar.  If the results of one or more of the audit elements are significantly different, an investigation into the reason(s) for the difference needs to be undertaken. Once the differences are resolved, electronic auditing then could be used as the primary source of audit data.   

Section 5 contains instructions for performing a manual audit.  If you will be performing an electronic audit, you may skip Section 5 and go directly to Section 6 (Performing an electronic audit).