ABSTRACT
Clerical audit of the problem-oriented medical record (POMR) is a brief review of practitioners' charts, which is conducted by medical assistants on each unit and supervised by unit managers. The idea of developing a clerical audit to monitor adherence to the POMR method was proposed by Dr. John Alcott when the methodology was developed. The unit manager monitored a certain number of audits performed by each assistant on his or her unit and the director of health services periodically compared the medical assistant's audit, the unit manager's review, and the actual chart. The initial projections about the number of charts which would be audited and the ability of medical assistants to perform the audit without interfering with their other duties have been borne out. The major problem has been inaccuracies in the audit, that is, misinterpretations or misunderstandings by medical assistants of the practitioners' progress notes.
