Enterprise · Clinical auditing

# Check clinical records against your criteria.

Review multiple records in one audit. See where documentation meets your criteria, where it falls short and the evidence behind each finding.

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Illustration with fictional records: a standard sweeps across a table of records and marks each one as met or not met.

## An example audit.

**Selected standard:** Does the record explicitly include a presenting complaint, examination findings and a follow-up plan? Target: 100%. Example data, six fictional outpatient records.

### Met (4)

- **DEMO-REC-001:** complaint, examination and follow-up plan all recorded.
- **DEMO-REC-003:** complaint, examination and follow-up plan all recorded.
- **DEMO-REC-004:** complaint, examination and follow-up plan all recorded.
- **DEMO-REC-006:** complaint, examination and follow-up plan all recorded.

### Not met (2)

- **DEMO-REC-002:** no follow-up plan found in the record.
- **DEMO-REC-005:** no examination findings recorded.

**Compliance:** 67%, below the 100% target.

**Evidence for DEMO-REC-002:** the presenting complaint (right knee ache after running for two weeks, no injury reported) and examination (full range of movement, no swelling, normal gait) were found. The follow-up plan was not found in this record. The standard needs all three parts, so this record does not meet it.

1. **Define the audit**
2. **Run the review:** the same criteria applied to every record.
3. **Act on the findings:** open the evidence.

## A clearer view of clinical documentation.

Auditing is available with Rhazes Enterprise.

### Your criteria

Audit against the questions and standards that matter to your team.

### Evidence for each result

Each finding links back to the record, so reviewers can check it.

### A view across records

Spot repeated gaps across records without tallying results by hand.

### Clinical oversight

Reviewers decide what the results mean and what happens next.

## Set the criteria. Review the evidence.

Setting up an audit takes four short steps in Rhazes.

1. **Purpose:** say what the audit is for.
2. **Standards:** write each standard in plain language, with who is included and any exceptions.
3. **Records:** add the records you want to review.
4. **Review:** check the setup, then run the audit.

## Questions from clinicians.

### Which plan includes auditing?

Clinical auditing is part of Rhazes Enterprise. Contact us about the records and criteria you need.

### Can we use our own audit criteria?

Yes. Define your criteria in plain language and apply them to the records you select.

### Does an audit result need human review?

Yes. Review the evidence and findings before using them to make clinical or operational decisions.

[Estimate time savings](https://www.rhazes.ai/benefits-calculator/)

## Where will you go next?

- [Medical coding](https://www.rhazes.ai/coding/): Review the evidence behind each code. Explore suggested medical codes linked to supporting clinical documentation.
- [Local guidelines & Spaces](https://www.rhazes.ai/spaces/): Keep your standards close. Organise the protocols and reference documents your team works from.
- [EHR integration](https://www.rhazes.ai/ehr-integrations/): Connect with your records. Discuss access to patient information through an Enterprise EHR connection.

Keep exploring: [AI medical scribe](https://www.rhazes.ai/scribe/) · [Clinical decision support](https://www.rhazes.ai/cdss/) · [Templates](https://www.rhazes.ai/templates/) · [Workflows](https://www.rhazes.ai/customisability/)

## Plan Rhazes for your organisation.

Contact us to discuss your records, clinical needs and Enterprise setup.

[Discuss Enterprise](mailto:contact@rhazes.ai?subject=Rhazes%20Enterprise) · [Compare plans](https://www.rhazes.ai/pricing/)

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