Free printable template · PDF
Chart Audit Form
A one-page chart review form for the medical director or delegate. Pull a sample of charts, check each one for the records a treatment should leave behind, and write down what was missing and what was done about it.
Free, no email needed. Guidance reviewed .
Chart Audit Form
MedSpaBinder
Clinic
Reviewer (name, credentials)
Review period
Charts reviewed / total
Mark each box Y (present), N (missing) or NA. Discuss every N with the provider and record the follow-up.
Reviewer signature: ______________________ Date: ____________ Charts with any N: ______ of ______
Why medical directors audit charts
Chart review is one of the main ways a medical director shows real oversight of the treatments done under their licence. Several states set a minimum amount of chart review for supervising physicians; where they don't, a regular audit is still the clearest evidence that supervision happened.
What each column checks
- Exam / GFE on file: a current good faith exam or assessment by an authorised provider before treatment.
- Consent signed: consent for this treatment, signed and dated before it was done.
- Product, lot, units / sites: enough detail to trace the product and repeat or correct the treatment.
- Before photos, aftercare and the provider's signature: the rest of a complete treatment record.
How to run the audit
- Pick a random sample each month or quarter, across every provider and treatment type.
- Mark each item and write the specific issue for every N.
- Talk each gap through with the provider, record the follow-up, and check the next audit for the same gap.
- Keep the completed forms with your medical director records.
Questions
How many charts should be reviewed?
Some states set a percentage or a number for supervising physicians; check yours. Otherwise, a fixed sample every month, such as 10 charts or 5% per provider, is common. What matters is that it's regular and recorded.
Should the audit form include patient names?
Use chart numbers. The form then says nothing about a patient if it's seen by someone who doesn't need to know.
General guidance, not legal or medical advice. Requirements vary by state; follow your medical director and product labels.