Children s Physiotherapy Records Audit Report 2014
Contents Introduction/Background... 2 Aim... 2 Objectives... 2 Standards... 2 Criteria... 3 Methodology... 3 Results... 3 Section A: Patient Identification... 4 Section B: Health Care Professional Identification... 5 Section C: Records and Notes... 6 Section D: Case Note Entries... 7 Section E: Do the notes Provide Clear Evidence...11 Section F Additional questions specific to Service / Team...12 Findings and Recommendations...14 Section A: Patient Identification...14 Section B: Health Care Professional Identification...14 Section C: Records and Notes...14 Section D: Case Note Entries...14 Section F: Additional questions specific to Service / Team...15 Conclusion...15 Action Plan...16 Appendix 1: Audit Team...18 Appendix 2: Audit Form...19 Appendix 3: Snap Online Instructions...23 (3) Childrens Physiotherapy Records Audit Report 2013 1
Introduction/Background The Children s Physiotherapy Team provides services to children and young people across Shropshire and Telford and Wrekin. Paediatric Physiotherapists within the service adhere to The CSP Code of Members Professional Values and Behaviour. These codes of professional values and behaviour for Physiotherapy are produced by the Chartered Society of Physiotherapy (CSP) which is the national professional body and trade union for physiotherapists throughout the United Kingdom. Point 2.1.2 of the code states: Complete records in accordance with legal ethical and organisational requirements. The Health Professions Council (HPC) regulates all Allied Health Professionals, including Physiotherapists and Standard 10 states: You must keep accurate records. Key reason for carrying out this audit was to comply with the requirements of the Clinical Record Keeping Policy (and related policies and procedures) in relation to auditing of patient records. It is also recognised that an audit will help to identify areas of concern as well as areas where good practice can be shared. It will also ensure that all staff involved in clinical record keeping are aware of the relevant requirements and ensure efficiency, professionalism and cost effectiveness in the clinical record keeping processes and procedures. Aim To ensure compliance with the relevant national, regional, professional and local clinical record keeping requirements Objectives 1. To give evidence based assurance that clinical record keeping standards and best practice is being carried out within the service 2. To identify any areas of concern within the clinical record keeping practices 3. To ensure a consistent approach to clinical record keeping practices 4. To highlight areas of good practice that can be shared with other services 5. To identify areas of concern and develop a action plans to resolve these matters 6. To identify gaps or areas for future training. Standards NHS Records Management Code of Practice Care Quality Commission Essential Standards for quality and safety Regulation 20, Outcome 21 Information Governance Toolkit Version 8 in particular Clinical Information Assurance requirements 8-400, 8-401, 8-402,8-404 and 8-406 (3) Childrens Physiotherapy Records Audit Report 2013 2
Criteria NHS Litigation Authority Risk Management Standards in particular clinical records related 1.1.8 and 1.4.4 NHSLA Clinical Record Keeping Policy NHS Number Retrieval, Verification and Use Procedure General Medical Council (GMC) Good Medical Practice: Guidance for doctors Nursing and Midwifery Council (NMC) Record keeping: Guidance for nurses and midwifes 2009. Health and Care Professionals Standards of Proficiency Physiotherapy 2013 The Chartered Society of Physiotherapy (CSP) Code of Members Professional Values and Behaviour The Chartered Society of Physiotherapy - Record Keeping Guidance PD061 Jan 2012 Records sourced from active caseloads from within the last three months from date of start of audit. Methodology Results The Audit team (see Appendix 1) developed the Record Keeping Audit Form (see Appendix 2) based on the Trust s Clinical Record Keeping Audit Template The Sample size and selection criteria agreed within clinical leads meeting with clinical leads and team lead - 2 records per 1 wte clinician to be audited. Records identified from active caseloads by team leader and given to staff to complete audit through joint peer review using SNAP audit tool Data was collected on the agreed audit form using the SNAP Online Audit Tool by using peer review. On completion of the data collection stage the data will be collated and exported into an Excel Spreadsheet for data analysis by the audit team The following part of the report is split into the different sections used in the audit form with data results for each question (note: these questions have been grouped together with graphs adjacent to give a visual representation of the results): Section A Patient Identification Section B Healthcare Professional Identification Section C Records / Notes Section D Case Note Entries Section E Do the notes Provide Clear Evidence (3) Childrens Physiotherapy Records Audit Report 2013 3
SectionA: Patient Identification Q1 Q2 Q3 Q4 Q5 Q6 Section F additional Questions specific to Service/Team Section A: Patient ID 1 Yes No N/A NHS Number (clearly & correctly documented) 92.9% (N=26) 7.1% (N=2) Forename (clearly & correctly documented) 10 (N=28) Surname (clearly & correctly documented) 10 (N=28) Date of Birth (clearly & correctly documented) 10 (N=28) Patient Number (i.e. any other relevant identification nu... 92.9% (N=26) 7.1% (N=2) Apart from the above, are there any other personal detail... 96.4% (N=27) Section A: Patient ID 2 Yes No N/A Q7 Patient contact details (Address, telephone number) 96.4% (N=27) Q8 Is the patient s gender recorded? 82.1% (N=23) 17.9% (N=5) Q9 Is the patient s ethnicity recorded? 89.3% (N=25) 10.7% (N=3) Q10 Are other relevant contact details recorded in 78.6% 21.4% the record (e.g. Next of Kin, Carers, Lasting (N=22) (N=6) Power of Attorney)? Q11 Where applicable, are the patient details recorded in the 96.4% (N=27) (3) Childrens Physiotherapy Records Audit Report 2013 4
Comments on Section A: 1. Q1 NHS number missing on assessment page, problem list and initial plans. NHS number was incorrect on the registration form, but correct on all other pages. 2. Q2 All good 3. Q3 All good 4. Q4 All good 5. Q5 All good 6. Q6 We came to the conclusion that the 1 file may have been created prior to the new recommendation 7. Q7 problem not specified only 1 file 8. Q8 gender highlighted as an administration error on initial registration 9. Q9 3 files did not record ethnicity 10. Q10 Significant number (6) of files did not have full parent/carer details 11. Q11 All good The audit highlighted a number of key issues: SectionB: HealthCareProfesional Identification Administration error for recording of gender Individual members of staff to record ethnicity and parent/carer detail Section B Health Care Professionals ID Yes No N/A Q13 Signed (identifiable signature) 10 (N=28) Q14 Printed Full Name 92.9% (N=26) 7.1% (N=2) Q15 Designation of staff in record or on signature 96.4% list in record. (N=27) Q16 Are all student entries countersigned by a qualified/ supervising staff member? 10 (N=28) Comments on Section B: 13 Q13 All good (3) Childrens Physiotherapy Records Audit Report 2013 5
14 Q14 Files identified immediately and corrected 15 Q15 1 File old notes without signature sheet 16 N/A The audit identified that: No significant action required SectionC: RecordsandNotes Section C: Records/Notes 1 Yes No N/A Q18 Are the records correctly filed (secure/safe 10 location and... (N=28) Q19 Is there a record tracing/tracking system in place? Q20 Is the folder in a good state of repair? (e.g. no tears or excessive use of sticky tape or staples, badly folded and/or damaged pages etc) 96.4% (N=27) Q21 Is the patient s name on every page? 75.0% (N=21) 10 (N=28) 25.0% (N=7) Q22 Q23 Q24 Q25 Q26 Section C: Records/Notes 2 Yes No N/A Is the patient's NHS number on 67.9% every page? (N=19) 32.1% (N=9) Are the record contents in 10 chronological order? (N=28) Do all the records in the folder 10 belong to the correct patient? (N=28) Is there a Medicine Log or Prescription Card in the records? Are all papers filed securely in the notes? (i.e. nothing loose) 78.6% (N=22) 96.4% (N=27) 21.4% (N=6) (3) Childrens Physiotherapy Records Audit Report 2013 6
Comments on Section C: 18 Q18 All good 19 Q19 Tracking system not used as only one case holder per file and then passed to admin when discharged. Admin aware that notes are held by individual clinicians 20 Q20 1 file needed replacing action taken at time of audit 21 Q21 7 files identified as requiring patient information on all pages specifically on exercise and activity sheets 22 Q22 9 files identified as requiring identification labels including NHS number 23 Q23 All good 24 Q24 All good 25 Q25 N/A 26 Q26 6 files required paper work securing In order to complete this section the record was looked at as a whole and a number of concerns were identified: SectionD: CaseNoteEntries The files must have patient identification on including the NHS number and names on all pages in file including exercise and activity sheets. All documentation should be filed securely. Section D: Case Note Entries 1 Yes No N/A Q28 Dated (day, month, year) 10 (N=28) Q29 Timed (hour and minute, 24hr clock or am/pm specified) 32.1% (N=9) 67.9% (N=19) Q30 Are the entries in the record consecutive? 10 (N=28) Q31 Are continuation sheets numbered? 89.3% (N=25) 10.7% (N=3) Q32 Are the entries in the record clearly written? 10 (N=28) Q33 Are the entries made in permanent ink and 10 readable when photocopied? (N=28) (3) Childrens Physiotherapy Records Audit Report 2013 7
Q34 Are there any abbreviations in the last entry? 78.6% (N=22) 21.4% (N=6) Section D: Case notes Entries 2 Yes No N/A Q35 If Yes, is the abbreviation written in full at first entry? 1 (N=3) 68.2% (N=15) 18.2% (N=4) Q36 Or is it an approved abbreviation? 72.7% (N=16) 18.2% (N=4) 9.1% (N=2) Q37 If applicable is there a list of approved 89.3% 10.7% abbreviations in the record? (N=25) (N=3) Q38 Are any alterations readable, dated, timed and signed? 66.7% (N=6) 33.3% (N=3) Section D: Case notes Entries 3 Yes No N/A Q39 Has any correction fluid been used to make alterations? Q40 Was appropriate consent obtained and recorded (i.e. written, verbal or implied)? Q41 Is the need for a Mental Capacity Act Assessment recorded? (Note: not applicable to under 16s) Q42 Have risk assessments been conducted and documented? Q43 Are there any subjective or offensive statements? 11.1% 96.4% (N=27) 88.9% (N=8) 7.1% (N=2) 10 (N=28) 92.9% (N=26) 92.9% (N=26) (3) Childrens Physiotherapy Records Audit Report 2013 8
Section D: Case notes Entries 4 Yes No N/A Q44 Are all relevant forms completed fully? 64.3% (N=18) 21.4% (N=6) 14.3% (N=4) Q45 Was the location of the consultation recorded (e.g. home... 96.4% (N=27) Q46 Was there a record made of other people present during the consultation (e.g. chaperone, carer, other healthcare professional)? Q47 Are the notes written in terms that a patient and/or parent/carer can understand? Q48 Are the notes written in terms that another professional involved in the care of the patient can understand? 82.1% (N=23) 78.6% (N=22) 10 (N=28) 10.7% (N=3) 21.4% (N=6) 7.1% (N=2) Section D: Case notes Entries 5 Yes No N/A Q49 Do the notes identify problems which have arisen? Q50 And, is the action taken to rectify them recorded? 92.9% (N=26) 89.3% (N=25) 7.1% (N=2) 10.7% (N=3) (3) Childrens Physiotherapy Records Audit Report 2013 9
Comments on Section D: 28 Q28 All good 29 Q29 19 files identified as not having the time of the appointment documented this was also identified in the last audit as a significant area for improvement. 30 Q30 All good 31 Q31 3 old files did not have numbered pages 32 Q32 All good 33 Q33 All good 34 Q34 significant inappropriate use of abbreviations 35 Q35 as Q34 36 Q36 as Q34 37 Q37 as Q34 38 Q38 3 files found to have been corrected without date, time and signature 39 Q39 1 file had correction fluid 40 Q40 1 old file without consent form 41 Q41 N/A 42 Q42 Unable to comment as no information was recorded in comment section 43 Q43 All good 44 Q44 Unable to comment as it was not clear from the audit which forms had not been completed 45 Q45 Only 1 file did not comply 46 Q46 5 files did not make a note of who was present 47 Q47 6 files were not written in terms that a patient or parent could understand 48 Q48 All good 49 Q49 acceptable compliance 50 Q50 acceptable compliance Omissions and concerns within this section that were highlighted included: (3) Childrens Physiotherapy Records Audit Report 2013 10
Lack of documentation of the timing of contacts and the people present Recognition of the lack formal documentation of risk assessments Misuse of abbreviations and jargon SectionE: DothenotesProvideClearEvidence Section E: Do the notes provide clear evidence of: 1 Yes No N/A Q52 Assessments carried out? 96.4% (N=27) Q53 The decisions made? 96.4% (N=27) Q54 The care planned? 10 (N=28) Q55 All required care delivered? 10 (N=28) Section E: Do the notes provide clear evidence of: 2 Q56 The notes having been written with the patient and / or parent / carer e.g. in discussions about assessment / plan / outcome? Q57 The information/leaflets shared with patient and/ or parent / carer? Yes No N/A 10 (N=28) 46.4% (N=13) 7.1% (N=2) 46.4% (N=13) (3) Childrens Physiotherapy Records Audit Report 2013 11
Comments on Section E: 52 Q52 All good 53 Q53 All good 54 Q54 All good 55 Q55 All good 56 Q56 All good 57 Q57 Leaflets not always relevant to patients SectionF Aditional questionspecifictoservice/ Team Section F: Additional Questions specific to Service/Team: 1 Q59 Are all correspondence filed in date order, most recent on top? Q60 Are copy correspondence photocopies (incl. signature) of the originals sent out? Q61 Where applicable, is consent to share information recorded? Q62 Details recorded of information shared and with whom? Q63 Are the reasons for sharing information recorded? Q64 If applicable, has the child/young person s competence been assessed and recorded in line with Fraser Guidelines? Yes No N/A 96.4% (N=27) 75.0% (N=21) 85.7% (N=24) 60.7% (N=17) 42.9% (N=12) Q65 Is a Significant Life Events Sheet being used? 7.1% (N=2) 7.1% (N=2) 17.9% (N=5) 14.3% (N=4) 21.4% (N=6) 17.9% (N=5) 7.1% (N=2) 35.7% (N=10) 39.3% (N=11) 85.7% (N=24) 78.6% (N=22) Section F: Additional Questions specific to Service/Team: 2 Yes No N/A (3) Childrens Physiotherapy Records Audit Report 2013 12
Q66 If applicable are there copies of case conference minutes in the record? Q67 If applicable, are there Core Group meeting minutes in the record? 10.7% (N=3) 7.1% (N=2) Q68 If applicable is relevant child protection supervision recorded in the notes? Q69 Are copies of referrals to Social Care included? Q70 Is an EKOS form filed in the notes? 96.4% (N=27) Q71 Is the EKOS form completed and updated? 39.3% (N=11) 10.7% (N=3) 10.7% (N=3) 10.7% (N=3) 60.7% (N=17) 78.6% (N=22) 89.3% (N=25) 85.7% (N=24) 85.7% (N=24) Comments on Section F: 59 Q59 All good 60 Q60 2 files indicated that physiotherapy letters had not been signed 61 Q61 2 files did not have written consent, this has improved since new paper work has been included in files. 62 Q62 acceptable compliance 63 Q63 5 files did not record reasons for sharing information 64 Q64 N/A 65 Q65 N/A 66 Q66 Reliant on MDT sending minutes of conferences/core group meetings even when contact information has been shared 67 Q67 as Q66 68 Q68 All good N/A 69 Q69 N/A 70 Q70 acceptable compliance 71 Q71 17 files did not have a completed or up to date EKOS form Within this section it was identified that: (3) Childrens Physiotherapy Records Audit Report 2013 13
Staff must sign letters prior to filing Staff need to document reasons for sharing information EKOS forms need to be up to date Findings and Recommendations SectionA: Patient Identification Some improvements were seen in documentation of PID however, further improvement could be made recording ethnicity and gender. This needs to be maintained. In the previous audit the information on the next of kin was not always filled in and this had not improved Action Communicate with the administration team with regards to the recording of gender on the front sheet of the physiotherapy file. Staff reminded to complete next of kin information. SectionB: HealthCareProfesional Identification Good compliance with the audit requirements SectionC: RecordsandNotes Compliance was good and broadly similar to those achieved in the last audit. Action Staff will be reminded that they need to check their notes to make sure that ALL paperwork, particularly exercise/activity sheets have PID and are secured effectively. SectionD: CaseNoteEntries Scores were low for compliance with documenting times of appointments in the entries on case notes. This has not improved since the last audit in 2011. Staff will need to be reminded of the importance of documenting this as it is a recurrent failing. Action Time will be allocated at the physiotherapy team meeting to review: The correct use of abbreviations and update the abbreviation list in particular in regard to MSK (musculo skeletal) casenotes. And discuss the need of risk assessment documentation in order to improve compliance. (3) Childrens Physiotherapy Records Audit Report 2013 14
SectionE: DothenotesProvideClearEvidence SectionF: Aditional questionspecifictoservice/ Team There was inconsistent compliance in this section. Written consent/ documentation has been maintained, however there is still room for improvement. Action Time will be allocated at the physiotherapy team meeting: to remind staff to sign letters prior to filing and to document reasons for sharing information Discuss the use of EKOS forms and whether they are relevant for all children e.g. MSK Conclusion Compliance with the audit standards was generally high and scores were broadly similar to those obtained in the previous audit. Specific improvements were seen in the recording of ethnicity. Compliance in several areas had either not improved or decreased. Particular areas identified were the use of abbreviations, recording time of appointments and updating EKOS forms. (3) Childrens Physiotherapy Records Audit Report 2013 15
Action Plan No Key Findings Recommendations/Actions Required Staff Member Responsible Timescales / Implementation Date 1. Areas of record keeping which require improvement Gender Next of kin details PID information of each page of the notes particularly page number and NHS number. This includes exercise and home programmes Present Audit findings and conclusions to Staff Meeting Communicate with the administration team with regards to the recording of gender on the front sheet of the physiotherapy file Iona James (IJ) and Jill Absolon (JA) IJ and JA July 2014 July 2014 Time of appointments Signing of letters before filing Recording the reason for sharing information with a specified person Securing all paper work in files 2. Incorrect use of abbreviations in notes Form a working party to review the current documents used and update list to include MSK abbreviations. All staff Working party to be identified June 2015 (3) Childrens Physiotherapy Records Audit Report 2013 16
No Key Findings Recommendations/Actions Required Staff Member Responsible Staff to have feedback on the audit to highlight incorrect use of abbreviations IJ and JA July 2014 Timescales / Implementation Date 3. Inconsistent use of EKOS forms All staff to be involved in the review of EKOS forms To discuss the relevance of EKOS forms in respect to MSK client groups All staff MSK team December 2014 Jan 2015 4. Re-audit to be carried out IJ and JA (2 years) July 2015 (3) Childrens Physiotherapy Records Audit Report 2013 17
Appendix 1: Audit Team Name Job Title Role within project (e.g. audit lead, supervisor) Iona James Clinical Lead in Transition Supervisor & Audit Lead Jill Absolon Clinical Lead in Early Years Supervisor & Audit Lead Chris Hodnett Clinical Lead in MSK Auditor Johanna Saunders Clinical Lead in Neonates Auditor Barbara Marsland Physiotherapist Auditor Chris Law Physiotherapist Auditor Helen Rhodes Physiotherapist Auditor Shibu Rasheed Physiotherapist Auditor Denise Featherstone Team Lead Auditor Ionela Pavel Physiotherapist Auditor Stephanie Benbow Physiotherapist Auditor Michelle Bramble Senior Clinical Audit Coordinator Coordination of SNAP online audit tool and collation of data Alan Ferguson Records Manager and Quality Facilitator Record management support and guidance (3) Childrens Physiotherapy Records Audit Report 2013 18
Appendix 2: Audit Form Clinical Record Keeping Audit Template Complete one form for each set of health records. Audit Name: Children s Physiotherapy Records Audit 2013 Directorate: Children and Families Service: Children s Physiotherapy Location: Coral House Stepping Stones Centre Record Audit Ref: _ Section A: Patient Identification (look at the front page / main page / summary / key details page) 1. NHS Number (clearly & correctly documented) Yes No 2. Forename (clearly & correctly documented) Yes No 3. Surname (clearly & correctly documented) Yes No 4. Date of Birth (clearly & correctly documented) Yes No 5. Patient Number (i.e. any other relevant identification number - clearly & correctly documented) Yes No n/a 6. Apart from the above, are there any other personal details about the patient on the outside cover? Yes No 7. Patient contact details (Address, telephone number) Yes No 8. Is the patient s gender recorded? Yes No 9. Is the patient s ethnicity recorded? Yes No 10. Are other relevant contact details recorded in the record (e.g. Next of Kin, Carers, Lasting Power of Attorney)? Yes No 11. Where applicable, are the patient details recorded in the paper record the same as recorded on the electronic clinical system? Yes No n/a 12. Comments for Section A (continue on additional page if required) Section B: Health Care Professional Identification (in particular look at the recent entries in the record) 13. Signed (identifiable signature) Yes No 14. Printed Full Name Yes No 15. Designation of staff in record or on signature list in record Yes No 16. Are all student entries counter signed by a qualified/supervising staff member? Yes No n/a 17. Comments for Section B (continue on additional page if required) (3) Childrens Physiotherapy Records Audit Report 2013 19
Section C: Records/Notes (look at the whole record for the patient) 18. Are the records correctly filed (secure/safe location and in correct order)? Yes No 19. Is there a record tracing/tracking system in place? Yes No 20. Is the folder in a good state of repair? (e.g. no tears or excessive use of sticky tape or staples, badly folded and/or damaged pages etc) Yes No 21. Is the patient s name on every page? Yes No 22. Is the patient s NHS number on every page? Yes No 23. Are the record contents in chronological order? Yes No 24. Do all the records in the folder belong to the correct patient? Yes No 25. Is there a Medicine Log or Prescription Card in the records? Yes No n/a 26. Are all papers filed securely in the notes? (i.e. nothing loose) Note: If there are loose items please list in comments section below. 27. Comments for Section C (continue on additional page if required) Yes No Section D: Case Note Entries 28. Dated (day, month, year) Yes No 29. Timed (hour and minute, 24hr clock or am/pm specified) Yes No n/a 30. Are the entries in the record consecutive? Yes No 31. Are continuation sheets numbered? Yes No 32. Are the entries in the record clearly written? Yes No 33. Are the entries made in permanent ink and readable when photocopied? Yes No 34. Are there any abbreviations in the last entry? Yes No 35. If Yes, is the abbreviation written in full at first entry? Yes No n/a 36. Or, if Yes, is it an approved abbreviation? Yes No n/a 37. If applicable is there a list of approved abbreviations in the record? Yes No n/a 38. Are any alterations readable, dated, timed and signed? Yes No No alterations 39. Has any correction fluid been used to make alterations? Yes No No alterations 40. Was appropriate consent obtained and recorded (i.e. written, verbal or implied)? Yes No 41. Is the need for a Mental Capacity Act Assessment recorded? (Note: not applicable to under 16s) Yes No n/a (3) Childrens Physiotherapy Records Audit Report 2013 20
42. Have risk assessments been conducted and documented? Yes No n/a 43. Are there any subjective or offensive statements? Yes No 44. Are all relevant forms completed fully? Yes No n/a 45. Was location of consultation recorded (e.g. home visit, clinic)? Yes No 46. Was there a record made of other people present during the consultation (e.g. chaperone, carer, other healthcare professional)? Yes No n/a 47. Are the notes written in terms that a patient and/or parent/carer can understand? 48. Are the notes written in terms that another professional involved in the care of the patient can understand? Yes Yes No No 49. Do the notes identify problems which have arisen? Yes No 50. And, is the action taken to rectify them recorded? Yes No n/a 51. Comments for Section D (continue on additional page if required) Section E: Do the notes provide clear evidence of: 52. Assessments carried out? Yes No 53. The decisions made? Yes No 54. The care planned? Yes No 55. All required care delivered? Yes No 56. The notes having been written with the involvement of the patient and / or parent / carer e.g. in discussions about assessment / plan / outcome? Yes No 57. The information / leaflets shared with patient and / or parent / carer? Yes No n/a 58. Comments for Section E (continue on additional page if required) Section F: Additional Questions specific to Service/Team: (additional questions applicable to specific audit/service requirements, some examples included) 59. Are all correspondence filed in date order, most recent on top? Yes No n/a 60. Are copy correspondence photocopies (incl. signature) of the originals sent out? Yes No n/a 61. Where applicable, is consent to share information recorded? Yes No n/a (3) Childrens Physiotherapy Records Audit Report 2013 21
62. Details recorded of information shared and with whom? Yes No n/a 63. Are the reasons for sharing information recorded? Yes No n/a 64. If applicable, has the child/young person s competence been assessed and recorded in line with Fraser Guidelines? Yes No n/a 65. Is a Significant Life Events Sheet being used? Yes No n/a 66. If applicable are there copies of case conference minutes in the records? Yes No n/a 67. If applicable, are there Core Group meeting minutes in the records? Yes No n/a 68. If applicable is relevant child protection supervision recorded in the notes? Yes No n/a 69. Are copies of referrals to Social Care included? Yes No n/a 70. Is an EKOS form filed in the notes? Yes No 71. Is the EKOS form completed and updated? Yes No n/a 72. Comments for Section F (continue on additional page if required) Data collector (1) Name:. Job title/role:. Tel No: Email:. Department:. Base:. Date completed:... /... /.. Data collector (2) if applicable Name:.. Job title/role: Tel No: Email:.. Department:.. Base: Based on Shropshire Community Health NHS Trust Clinical Record Keeping Form Template V7 Jun 2012 (3) Childrens Physiotherapy Records Audit Report 2013 22
Appendix 3: Snap Online Instructions To complete the Clinical Record Keeping audit using the SNAP online tool click on the link provided: http://www.shropscommunityhealth.nhs.uk/content/page/20274/physiotherapyrecordkeepingaudit.htm The Audit form will open with the initial information page. Complete the details including the Records Audit Reference number which is a pseudonymised number derived from the patient s initials and last four of their NHS Number as advised in the audit planning stage e.g. Any Body NHS number 123 456 7890 would be AB 7890. For location ensure you enter either Coral House or Stepping Stone Centre. Progress through the form ensuring you complete all questions in each section. If a question is missed out a dialogue box will be displayed and the question concerned will be highlighted with a red border. At the end of sections there is a comments box which you should use to record any relevant points that will help explain or expand on topics covered in that section. Please precede any comments with the question number it relates to e.g. as below Q11 Patient mobile telephone number in paper... Please add additional comments on separate lines, preceding each comment with the relevant question number. At the end of the audit enter the details of the staff carrying out the audit. When you have completed the audit click on Submit. There will be a short pause while the information is prepared and then sent for processing. Once this is completed, you will be routed back to the first page of the audit tool. If you have finished the audit then just close down this window. (3) Childrens Physiotherapy Records Audit Report 2013 23