To start a documentation review at a site select Gather Evidence and then Review Documentation in the navigation menu.
The Content Page on the right lists only those sites that were marked as Visited in the Site Sampling Summary. If a site is not listed, click on the Add or Edit visited Sites to change your selection of visited sites.
To start your first review, click on the Add or Edit button next to the site that you are visiting.
The Content Page lists only those question within the audit that must be verified through documentation review and it lists each question as it appears in the protocol.
Clicking on the more link below each question will expand the question to reveal additional information. These guidelines provide more detail on what to look for, and how to score your findings.
Based on the evidence reviewed record your findings in point-form in the Comments section. These Comments are used later to compose a formal answer to the audit question. It is recommended that you keep your notes short and to the point because are only reviewing documentation at one site and have not completed the interview and observation steps, and do not know if the evidence from those steps will support your initial findings. Also see Dictation and Voice Recognition
Next assign a % Compliant indicating to what degree the reviewed evidence meets the audit requirements. You should assign the percentage in accordance with the question’s guidelines. The available scoring options are determined by the audit protocol. There are 3 common formats:
Yes / Partial / No - where the % assigned to each option is Yes (100%), Partial (50%) and No (0%)
Yes / No - where the % assigned to each option is Yes (100%) and No (0%)
% Positive indicators - based on evidence reviewed a % is assigned based on positive indicators in a sample (for more information see below).
IMPORTANT: Note, the % Compliant is not the same as the scoring the audit question. The question score is automatically calculated based on the total % Compliant assigned across all the visited sites. Scoring is covered in the Audit Results section.
% Positive Indicators
To determine how the % positive indicators is calculated click on the information icon at the top of the page and an explanation will popup explaining the data should be entered.
Question Dependencies
The answers of some questions may be dependent on the response to a prior questions - for more information please see Questions Dependencies
Articles for Documentation: