Audit printables sample 2025

1. Click ‘Get Form’ to open the audit printables sample in the editor.
2. Begin by entering the patient’s name and MRN number at the top of the form. This information is crucial for identifying the patient.
3. Fill in the Admit/Disc Date and Level Billed fields. Ensure accuracy as this impacts billing and record-keeping.
4. In the Chief Complaint section, provide a concise description of the patient's primary issue. This sets the context for further evaluation.
5. For History of Present Illness (HPI), check relevant boxes and provide details on location, severity, quality, duration, and associated symptoms as applicable.
6. Complete Past, Family, Social History (PFSH) by checking appropriate options and detailing any pertinent medical history.
7. Review each system in Review of Systems (ROS) and mark any relevant findings to ensure comprehensive documentation.
8. Proceed to fill out the Exam section by selecting appropriate options based on your findings during the examination.
9. In Decision Making, evaluate complexity and associated risks based on your clinical judgment and document accordingly.

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