Development of an audit tool for the outpatient safety program

A process for auditing physician documentation in the medical record related to patient safety was needed at McConnell Air Force Base (AFB). McConnell's Medical Clinic abides by the Joint Commission's Ambulatory Health Care's National Patient Safety Goals. The physicians at the Medical Clinic document in the electronic medical record, AHLTA. The documentation criteria in the Joint Commission's Ambulatory Health Care's National Patient Safety Goals must be met for the sake of patient safety and quality care. Following a focused literature search on documentation regulations and auditing processes, an audit process and tool was developed to assist in determining documentation compliance with the National Patient Safety Goals. The audit process and tool allow the Patient Safety Manager to track and trend documentation for process improvement purposes.