The process of conducting documentation audits involves several steps: 1. Selection of Records: Randomly selecting patient records for review. 2. Review Criteria: Establishing criteria based on regulatory guidelines and institutional policies. 3. Audit Team: Assembling a team of auditors, often including nurses, quality assurance personnel, and sometimes external experts. 4. Data Collection: Reviewing the selected records against the established criteria. 5. Analysis and Reporting: Analyzing the findings and preparing a report that highlights areas of compliance and non-compliance.
