Action Clinical Documentation Audit Tool for Continuing Healthcare Teams This audit tool has been devised to monitor the standard of documentation at a local level and form a basis for discussion, measurement and improvement in compliance with the NMC Guidelines for Record Keeping (2012), Arden and Greater East Midlands Commissioning Support Unit s (Arden & GEM CSU) Clinical Records Management Policy and the Arden and GEM Standards for MDT/DST (2014). Team Name: Team Location: Arden and GEM recommends that compliance with the NMC Guidelines for Record Keeping and the Arden & GEM CSU Clinical Records Management Policy be audited twice yearly CHC teams will buddy up with other CHC teams to complete audits (therefore teams do not complete their own audits) Following the completion of the audit the results will be fed back on a documentation audit results template to the clinical quality team The results should be shared with the clinical team and the Clinical Quality and Safety Committee In the event of non-compliance, an action plan should be drawn up by the team lead and monitored locally with evidence of completion of actions provided to the Clinical Quality and Safety Committee 20 Decision Support Tool (DST) documents which have been completed within the past 3 months by the local team should be audited Undertake the audit by completing the audit tool below for each DST reviewed. Review 20 DSTs and answering each question by ticking Yes, No or N/A. 1. Section 1 General Principles 1 Are all records legible? 2 Are all records completed in black ink? 3 Is the date on every sheet/page? 4 Is the patient s name on every sheet/page? 5 Is the patient s NHS number on every sheet/page? 6 Is the name of the lead clinician clearly recorded? 7 Are any additional pages/sheets clearly labelled? 8 Is the evidence within each domain presented in clear, sequential order? 9 Are statements clear and understandable? 10 Are any abbreviations used correctly? (Abbreviations can only be used where a glossary also forms part of the record and the abbreviation is written in full the first time it is used) 11 Are all corrections/errors corrected by crossing through with a single line? 12 Are all corrections/errors signed? 13 Are all corrections/errors dated? Clinical Documentation Audit Tool July 2015 1
2. Section 2 Biographical Information Does the DST document contain the following?: 1 The patient s full name? 2 A record of the patient s NHS number? 3 The patient s full address? 4 The patient s date of birth? 5 The patient s contact details? 6 The name of the patient s General Practitioner? 7 A record of the patient s ethnicity? 8 A record of the patient s religion? 9 A record of the patient s current medication? 10 A record of the patient s previous health history? 11 A record of the patient s mental capacity? 12 A record of consent/best interest to undertake the DST 13 A record of consent/best interest to share information? 14 A record of any representative acting on behalf of the patient, their relationship and authority to act? 15 A record within the pen portrait of social circumstances and any dependents? 3. Section 3 MDT/Recommendation 1 Is there evidence that the purpose of the MDT/DST has been explained to the patient/family/carer? 2 Is there evidence that the role of the MDT members has been explained to the patient/family/carer? 3 Is there evidence that the role of the patient/family/carer in the MDT has been explained? 4 Is the MDT appropriately constituted? (Two professionals who are from different healthcare professions, or one professional who is from a healthcare profession and one person who is responsible for assessing individuals for community care services) Clinical Documentation Audit Tool July 2015 2
5 Is there evidence of involvement and discussion with the patient/family/carer within the MDT/DST? 6 Have the views/opinions of the patient/family/carer been recorded? 7 Does each care domain evidence needs? 8 Does each care domain evidence risks? 9 Does each care domain evidence intervention? 10 Is each domain level sufficiently evidenced? 11 Does the rationale clearly consider nature? 12 Does the rationale clearly consider intensity? 13 Does the rationale clearly consider complexity? 14 Does the rationale clearly consider unpredictability? 15 Does the recommendation clearly state whether there is/is not a Primary Healthcare Need? 16 Have all the MDT Members signed the DST? 4. Scoring Table for Each Individual Record SECTION MAXIMUM SCORE SCORE % SCORE Section 1 General Principles 13 Section 2 Biographical Information 15 Section 3 MDT/Recommendation 16 Total Overall Score 44 Scoring Guide: Yes = 1, No = 0, N/A = 1 Score: The number of Yes s and N/A s added together : Score divided by maximum score multiplied by 100 Clinical Documentation Audit Tool July 2015 3
5. Scoring Table for Overall Audit (To be completed when each individual record has been scored in the above table) Record Number 1 2 General Principles Biographical Information MDT / Recommendation Overall Record 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Overall Any overall scores for each section of 90% or less will require an action plan to be developed. Audit Completed By: Job Title: Signature: Date of Audit: Action Plan Clinical Documentation Audit Tool July 2015 4
Required? Clinical Documentation Audit Tool July 2015 5