Chart Audit Nurse Jobs (2025)

FAQs

What does an RN chart auditor do? ›

A nursing audit consists of collecting information from nursing reports, medical notes and other patient care records to help assess the quality of care. Therefore, a nurse auditor is responsible for managing medical records in healthcare settings and insurance companies.

The qualifications that you need to become a chart review nurse or utilization review nurse include a nursing degree, nursing license, and analytical skills to assess and make decisions based on charts and medical data.

As a chart review nurse, you review patient healthcare information and records. Your duties include defining the level of care, determining the necessity of procedures related to diagnosis, and assessing discharge procedures.

A nurse auditor's job is to oversee medical records and make sure that everything is coded correctly, ensuring optimal outcomes for both the patient and the hospital.

How Do I Become a Medical Auditor? You will need at least an associate's degree in health information or a similar field, where you will learn critical coding concepts and medical record auditing skills. Certification as a professional medical auditor is required by some states.

Yes, utilization review nursing can be stressful because it ensures patients receive the appropriate level of care.

Yes, many nurses find charting to be tedious. But make no mistake — effective charting helps prevent errors, helps recover from quickly from illness and injury more quickly, and helps keep patients safe and healthy in general.

How often do hospitals audit charts? ›

These audits are run by HIM staff on at least a monthly basis and various “triggers” are set up and automatically run against patient rosters and access logs. An example might that an alert is tripped when a staff member is in the chart of someone who has the same last name or address.

Can Researchers Legally Look at Patients' Medical Records Without Their Consent? Chart review research without patient consent is legal under federal laws in the United States under certain conditions; state laws vary.

Your responsibilities include assessing medical records to decide whether there is a valid reason for treatment or denial of care and ensure that the quality of patient care abides by health care policies and standards. In some cases, an RN chart auditor speaks with healthcare providers to verify the information.

Nursing audit process has six phases: Planning phase, preparation phase, implementing phase, analysis and finding gap phase; improvement phase and sustaining improvement phase.

The purpose of nursing audit should be for planning, evaluation, education and research, and improving nursing practices and procedures up to the satisfaction of patients. This needs to be introduced in all the hospital, institution by trained experts and motivating administrators at all levels.

A chart audit is an examination of medical records (electronic and/or hard copy), to determine what has been done, and see if it can be done better.

Perhaps the most beneficial use for a chart audit is to measure quality of care so that you can improve it. Chart audits are often used as part of a quality improvement initiative. For example, a practice might review charts to see how often a particular vaccine is offered, given or declined.

So what does a person who is a Registered Auditor do (RAs)?

In expressing the opinion an auditor would typically audit the accounting systems, procedures and financial statements of a company, and would evaluate the way in which the company manages corporate funding and financial risk.

Nursing audit is a process to evaluate the quality of nursing care provided by reviewing patient records and care documentation. It involves collecting information from nursing reports and patient records to assess the quality of care provided based on quality standards.