0.2. THESIS APPROACH
1.1.2. Una aproximación pragmático-discursiva al «constructivismo»
Clinical Record Keeping Audit Template
Record Audit Ref: _ _ _ _ _ _ _ _ _ Complete one form for each set of health records.Return all forms to <<insert details>> once completed.
Audit Name: ………
Directorate: ……….. Service: ………. Department: ……….……… Location: ……… 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
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.
Yes No
27. Comments for Section C (continue on additional page if required)
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
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?
Yes No
48. Are the notes written in terms that another professional involved in the care of the patient can understand?
Yes 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 and / or 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 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. Comments for Section F (continue on additional page if required)
Data collector (1) Data collector (2) if applicable
Name: ………. Name: ………..
Job title/role: ………. Job title/role: ………
Tel No: ……… Tel No: ………
Email: ………. Email: ………..
Department: ………. Department: ………..
Base: ………. Base: ………
Date completed: ….... /…..…. /………..
Please note that this is a template for Clinical Record Keeping Audits. The Records Manager must be consulted when adapting the template for a specific service or department. This is to ensure a consistent approach to clinical record keeping audits throughout the organisation. Audits can be set up as online versions in order to make data collection and analysis more efficient. The Records Manager can give advice and guidance on this process.
Alan Ferguson, Records Manager, Shropshire Community Health NHS Trust Tel: 01743 277617
E-mail: [email protected]