Which of the following best represents what a medical record audit assesses?

• A. Documentation quality and timeliness only.
• B. Policy adherence only.
• C. Timeliness and patient satisfaction scores.
• D. Documentation quality, timeliness, legibility, and policy adherence.

Answer: (D)

Medical record audits look at how well patient notes meet standards for quality and use. They assess how complete and accurate the documentation is (documentation quality), whether notes are entered in a timely fashion (timeliness), how readable and clear the records are (legibility), and whether the records follow established policies and guidelines (policy adherence). Together, these elements ensure records support safe, legal, and efficient care and proper coding and compliance.

That’s why the best choice includes all four aspects: documentation quality, timeliness, legibility, and policy adherence. The other options miss one or more important areas—for example, focusing only on policy adherence ignores the quality and clarity of the actual documentation, or emphasizing patient satisfaction without addressing the content and policy standards of the record.