Clinical Audit Procedure for NHS-LA and CNST Casenote Audit

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1 Clinical Audit Procedure for NHS-LA and CNST Casenote Audit NHS Litigation Authority (NHS-LA) Risk Management Standards for Acute Trusts Pilot Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical Risk Management Standards Name and title of author Tracy Evans, IPOC Manager Date written January 2009 Approved by (Committee/Group) Date of approval February 2009 Date issued November 2009 Next review date November 2012 Target audience Trust-wide Clinical Audit, Research and Effectiveness Group Clinical Records Committee WARNING: Always ensure that you are using the most up to date approved procedural document. If you are unsure, you can check that it is the most up to date version by looking on the Trust Website: under the headings Freedom of Information Information Classes Policies and Procedures Page 1 of 25

2 Contents Page Number Section 1: Key Principles of the Procedure Introduction Procedure Statement Definitions Legal Obligations and Best Practice Roles and Responsibilities 5 Section 2: Documentation Documentation Instruction Standards 6 Section 3: Monitoring Compliance and Effectiveness Divisions Corporate Non-compliance 6 Section 4: Appendices 7-25 Appendix 1 NHS-LA Casenote Audit Rolling Programme 7 Appendix 2 General Casenote Audit 8-12 Appendix 3 Documentation Standards Appendix 4 Report Template Page 2 of 25

3 1. KEY PRINCIPLES OF THE PROCEDURE 1.1. Introduction Record Keeping is an integral part of healthcare practice. Good practice in record keeping can help to protect the welfare of patients by ensuring high standards and continuity of care and better communication between members of the health care team (NMC 2005). One way to ensure that high standards of record keeping are maintained is through clinical audit. Through audit one can assess the standard of the record and identify areas for improvement There are published documents that provide guidance on good record keeping practice: CORP/REC 5 Clinical Records Policy Doncaster and Bassetlaw Hospitals NHS Foundation Trust, 2007 Generic Medical Record-Keeping Standards Connecting for Health, 2007 Good Medical Practice General Medical Council, 2006 Guidelines for Records and Record Keeping Nursing and Midwifery Council, 2005 NHSLA Risk Management Standards for Acute Trusts NHS Litigation Authority, 2009 CNST Maternity Record Management Standards NHS Litigation Authority, 2008 Good Surgical Practice Royal College of Surgeons of England, 2008 Core Standard of Physiotherapy Practice, 2005 A Guide to Good Medical Practice for Clinical Radiologists The Royal College of Radiologists, 2004 Good Practice: A Guide for Departments of Anaesthesia, Critical Care and Pain Management The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland, 2006 Guidelines for Best Practice No 3 Clinical Records British Association of Prosthetists and Orthotists, 2002 Guidance on Standards for Records and Record Keeping Joint BDA / Dietitians Board, 2003 Page 3 of 25

4 Professional Standards for Occupational Therapy Practice College of Occupational Therapists, 2007 Reference Guide to Consent for Examination or Treatment Department of Health, 2001 British National Formulary British Medical Association, 2007 Handbook for Junior Medical Staff Doncaster and Bassetlaw Hospitals NHS Foundation Trust, The Department of Clinical Audit, Research and Effectiveness (CARE) have a responsibility to ensure that a rolling Casenote Audit programme is in place across the Trust 1.2. Procedure Statement This procedural document aims to ensure that all staff within Doncaster and Bassetlaw Hospitals NHS Foundation Trust are aware of their responsibilities relating to the auditing of Casenotes The Casenote audit is undertaken in accordance with NHS-LA Standards, the Trust s Clinical Records Policy (CORP/REC 5) and Policy for the Order of Filing in the Casenotes (CORP/REC 1) Definitions Casenotes A corporate folder which holds the health record Clinical Audit The systematic critical analysis of the quality of clinical care, including the procedures used for diagnosis, treatment and care, the associated use of resources and the resulting outcome and quality of life for the patient Contemporaneous Occurring in the same time period of time, i.e. writing of notes during or immediately after the care or treatment has been given NHS-Litigation A special Health Authority established in 1995 to administer the Clinical Negligence Scheme for Trusts (CNST) and thereby provide a means for NHS organisations to fund the cost of clinical negligence claims Record-Keeping The process of writing information on treatment, conversations etc as a record of evidence that the action has taken place Page 4 of 25

5 1.4. Legal Obligations and Good Practice NHS-LA Clinical Care Standard 4: Level 1 The organisation has approved documentation which describes the process for managing the risks associated with the quality of clinical records in all media Level 2 The organisation can demonstrate implementation of the approved documentation which describes the process for managing the risks associated with the quality of clinical records in all media Level 3 The organisation can demonstrate that there are processes in place to monitor compliance with the approved documentation which describes the process for managing the risks associated with the quality of clinical records in all media Roles and Responsibilities Divisional Manager It is the responsibility of the Divisional Manager to ensure that the NHS-LA Casenote Audit is completed in accordance with the rolling programme. No reminders will be issued Clinician It is expected that clinicians will undertake monthly audits against these standards on 20 sets of patient records following the rolling programme set by Department of CARE (Appendix 1). The audit should include assessment of all aspects of the record including entries by medical staff, nursing staff and clinical therapy. This audit can be done with a team consisting of these professionals auditing a set of notes together or as independent audits by each professional group within the directorate. It is acknowledged that most directorates will already be undertaking larger audits than the minimum and this is welcomed and encouraged by Clinical Audit, Research and Effectiveness Department Clinical Audit Leads Clinical Audit Leads should ensure that the audit reports are fed back to the divisions via the audit and governance half day and an action plan completed (see appendix 4) and returned to the Department of CARE with the audit and governance minutes Clinical Audit, Research and Effectiveness (CARE) Department The CARE Department will produce an annual report for the Patient Safety Review Group which will include details of records audit undertaken and a summary of significant action undertaken across the Trust Page 5 of 25

6 2. DOCUMENTATION CORP/COMM 15 v Documentation To support Divisions with this project there is an NHS-LA Casenote Audit Proforma available electronically (see Appendix 2) 2.2. Instruction Proforma are available to complete electronically and are accessible on [either type the above in the address bar on the intranet, or press start button, run and type the above in the field] Each set of 20 proforma is to be completed by the end of each indicated month for analysis and reporting Should an action plan highlight a need for re-audit, the Department of CARE will negotiate with the department and support the re-audit process Standards Each proforma has Doncaster and Bassetlaw Hospitals NHS Foundation Trust Standards for Record-Keeping as set out in the Clinical Records Policy (CORP/REC 5) and also incorporate professional standards from each of the Royal Colleges / Associations Copies of the standards for each of the proforma can be found in appendix 3 3. MONITORING COMPLIANCE AND EFFECTIVENESS 3.1. Divisions Divisional teams are expected to review the action plans and undertake any identified actions as they feel are appropriate The Clinical Records Committee is expected to review the quarterly reports and action plans and undertake any actions they feel appropriate Annually each Division will produce a summary detailing any changes that have been, or are being, implemented and any outstanding issues. These will be collated by the Department of CARE 3.2. Corporate The Department of CARE will produce an annual report for the Patient Safety Review Group which will include the findings from the records audit. Should any of the records audits produce evidence of major significance these will be reported by exception 3.3. Non-compliance All non-compliance will be reported to Patient Safety Review Group. Page 6 of 25

7 APPENDIX 1 NHS-LA Casenote Audit Rolling Programme November 2009 October 2012 CORP/COMM 15 v.1 November 2009 Day Surgery Surgery December 2009 Theatre Admission Unit Surgery January 2010 Diagnostic Day Unit Medicine February 2010 Ear, Nose and Throat Surgery March 2010 Renal Services Medicine April 2010 Dietetics Clinical Therapy May 2010 Gastroenterology Medicine June 2010 Orthopaedic Surgery July 2010 Physiotherapy Clinical Therapy August 2010 Oral Surgery Surgery September 2010 Paediatrics Family Health October 2010 Cardiology Medicine November 2010 Breast Services Surgery December 2010 Diabetes and Endocrinology Medicine January 2011 General Surgery Surgery February 2011 Gynaecology Family Health March 2011 Ophthalmology Surgery April 2011 Pain Management Diagnostic/Clinical Support May 2011 Dermatology Medicine June 2011 CAMHS Family Health July 2011 Occupational Therapy Clinical Therapy August 2011 Rheumatology Medicine September 2011 Speech and Language Therapy Clinical Therapy October 2011 Urology Surgery November 2011 Respiratory Medicine Medicine December 2011 Rehabilitation / Elderly Medicine Medicine January 2012 Critical Care Diagnostic/Clinical Support February 2012 General Medicine Medicine March 2012 Genito-Urinary Medicine Family Health April 2012 Orthodontic Surgery May 2012 Drug and Alcohol Medicine June 2012 Neonatology Family Health July 2012 Orthotics / Appliances Clinical Therapy August 2012 Vascular Surgery September 2012 Haematology Medicine October 2012 Theatres Diagnostic/Clinical Support November 2012 Obstetrics Family Health Page 7 of 25

8 APPENDIX 2 CORP/COMM 15 v.1 Page 8 of 25

9 Page 9 of 25 CORP/COMM 15 v.1

10 Page 10 of 25 CORP/COMM 15 v.1

11 Page 11 of 25 CORP/COMM 15 v.1

12 Page 12 of 25 CORP/COMM 15 v.1

13 APPENDIX 3 Standards for Doncaster and Bassetlaw Hospitals NHS Foundation Trust NHS-LA Records Audit *** ONLY OFFICIAL PROFORMA FROM DEPARTMENT OF CARE WILL BE ANALYSED *** The following contains core standards for good record keeping practice in this Trust. Where applicable the standards should be audited against as a minimum The standards are to be used by clinical staff as a basis for continued documentation audit The minimum requirement for this audit is 20 sets of casenotes monthly, analysed in a quarterly report. All completed proforma should be submitted to the Department of CARE by the end of each indicated month Where practice fails to meet the standard, directorates are encouraged to write an action plan and re-audit The Department of CARE will formulate quarterly reports for the Trust as a whole Each Directorate is to review the quarterly report and action plans in the Audit and Governance half day each quarter The Trust report and action plans will be discussed at CARE meeting and Clinical Record Committee each quarter. Page 13 of 25

14 Criteria Evidence Base Standards 1. The clinical record contains the following identification data on each clinical sheet, 1 st page of an IPOC, radiology requests and on the casenote itself: a. Patient name b. Unique identifier 2. The clinical record contains a referral source (including contact name / number if applicable) Good Medical Practice, General Medical Council (2006) Guidelines for Records and Record Keeping, Good Practice: A Guide for Departments of Anaesthesia, Critical Care and Pain Management, The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland (2006) Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) 100% of documentation in clinical records contains a full patient name 100% of documentation in clinical records contains a unique identifier 100% of clinical records have a referral source recorded 100% of Radiology Requests have Name and signature of referred and contact details Page 14 of 25

15 3. The name of the consultant in charge for the episode of care must be recorded (where applicable). 4. Initial patient contacts and all subsequent entries must be dated and timed Guidelines for records and record keeping, Good Practice: A Guide for Departments of Anaesthesia, Critical Care and Pain Management, The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland (2006) Guidelines for records and record keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) 100% of records should contain the name of the consultant in charge of the patient. 100% of entries should be dated. 100% of entries should be timed. Page 15 of 25

16 5. Within the initial patient contact there should be recorded evidence of the presenting problem and a list of problems 6. There should be clear evidence of the provisional diagnosis and subsequent management plan. Good Medical Practice, General Medical Council (2006) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Good Medical Practice, General Medical Council (2006) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) 100% of entries state a presenting problem 100% of entries contain a problem list 100% of records should have documented evidence of the suspected diagnosis. 100% of records should have documented evidence of a treatment plan. Page 16 of 25

17 7. All alerts and sensitivities are recorded within the casenotes 8. Investigation(s) (intention and result) should be recorded in the casenotes for initial patient contact A Guide to Good Medical Practice for Clinical Radiologists, The Royal College of Radiologists (2004) Good Practice: A Guide for Departments of Anaesthesia, Critical Care and Pain Management, The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland (2006) Good Medical Practice, General Medical Council (2006) 100% of allergies and drug sensitivities are recorded on the Alert / Hazard Notification in the casenotes 100% of allergies and drug sensitivities are recorded at initial patient contact 100% of allergies and drug sensitivities are recorded on the Anaesthetic Record in the pre-operative assessment 100% of allergies and drug sensitivities are recorded on the Prescription Chart 100% of investigations intention and results is stated in the casenotes at initial patient contact (where investigations are required) Page 17 of 25

18 9. When making an entry the clinician should sign, print their full name and grade/designation at the end of their entry 10. Bleep number (if a bleep is held) should be recorded after every entry in the casenotes 11. Prescription Each patient will have a prescription chart or electronic record for the current episode of care (if applicable) Guidelines for Records and Record Keeping, Good Practice: A Guide for Departments of Anaesthesia, Critical Care and Pain Management, The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland (2006) Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Handbook for Junior Medical Staff, DBHNHSFT (2006) Prescribing Standards DBHNHSFT (2008) 100% of clinical staff should sign each entry made in the clinical notes 100% of clinical staff should print their full name after each entry made in the clinical notes 100% of clinical staff should state their grade / designation after each entry in the clinical notes 100% of records should contain a bleep number if the clinician holds a bleep 100% of appropriate patients have either an electronic or paper prescription record Page 18 of 25

19 12. Prescription Discontinued medications are deleted with a single line, signed, dated and timed. 13. Prescription Each entry for prescribed medication will have a start date 14. Prescription Each entry for prescribed medication will be signed 15. The record is written indelibly, in black ink (or agreed alternative), to enable it to be photocopied if necessary and are legible Prescribing Standards DBHNHSFT (2008) Prescribing Standards DBHNHSFT (2008) Prescribing Standards DBHNHSFT (2008) Good Medical Practice, General Medical Council (2006) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) British National Formulary, British Medical Association (2007) Handbook for Junior Medical Staff, DBHNHSFT (2006) Page 19 of % of discontinued medications are scored out with a single line 100% of discontinued medications are signed 100% of discontinued medications are dated 100% of discontinued medications are timed 100% of prescribed medication have a start date 100% of prescribed medication are signed 100% of entries are made in black ink or agreed alternative 100% of entries made within the casenotes are legible 100% of medication entries made on the prescription chart are written in black ink 100% of amended entries on the prescription chart are in green ink

20 16. All entries are written in plain English (in a way a patient can understand) 17. The record should demonstrate an accurate chronology of the patients progress 18. The record does not contain blank lines or empty space. Where entries are made on documents that result in blank space under an entry, this space should be crossed through with a line. Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) British National Formulary, British Medical Association (2007) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) 100% of records are written in plain English and only contain abbreviations that are recognised and accepted. 100% of records should provide a chronological account of the patient s progress. 100% of blank spaces have a line crossed through to prevent entries being made retrospectively Page 20 of 25

21 19. The record is written contemporaneously 20. Medical entries are made once each 24 hours (5 day week) for acute conditions and at least twice per week for rehab. Nursing entries are made at least once per shift 21. Any alteration is scored out with a single line, signed, dated and timed. Good Medical Practice, General Medical Council (2006) Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Guidelines for Records and Record Keeping, Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) 100% of entries are written at the time of the event or as soon as possible afterwards 100% of medical entries adhere to guidance Nursing entries have been made at least once per shift in 100% of cases 100% of alterations are scored out with a single line so that the original entry can still be read 100% of alterations are signed 100% of alterations are dated 100% of alterations are timed Page 21 of 25

22 22. All interventions / procedures should be written fully and detailed in the casenotes 23. Surgical Team Only Details of operation are written legibly and in full 24. Surgical Patient Only All consent forms will be signed by a suitably trained and qualified clinician 25. Surgical Patient Only All consent forms will be signed by the patient (where they are fit and able to do so) 26. Surgical Patient Only All consent forms should be written legibly Guidelines for Records and Record Keeping, Guidelines for Best Practice No 3: Clinical Records, British Association of Prosthetists and Orthotists (2002) Guidance of Standards for Records and Record Keeping, Joint BDA / Dietitians Board (2003) Professional Standards for Occupational Therapy Practice, College of Occupational Therapists (2007) Reference Guide to Consent for Examination or Treatment, Department of Health (2001) Reference Guide to Consent for Examination or Treatment, Department of Health (2001) Reference Guide to Consent for Examination or Treatment, Department of Health (2001) Reference Guide to Consent for Examination or Treatment, Department of Health (2001) Reference Guide to Consent for Examination or Treatment, Department of Health (2001) 100% of interventions / procedures carried out by clinical staff have been written in full (planned or carried out) 100% of operations are written in full 100% of operations are written legibly 100% of consent forms are signed by a suitably trained and qualified clinician 100% of consent forms have been signed by a patient 100% of consent forms are legible Page 22 of 25

23 APPENDIX 4 CORP/COMM 15 v.1 REPORT TEMPLATE (Available electronically from the Department of CARE) Project Title: Audit of Patient Records in.. Project Lead(s):.. Aims & Objectives: (suggested text) The main aim of this project was to examine current record keeping at DBH NHSFT and look at ways in which existing practice could be improved. The objectives were to: identify adherence to the Trust s record keeping standards identify factors that may be contributing to any failures in meeting the standards make recommendations for future practice at DBH Methods: 20 sets of casenotes were audited retrospectively using the NHS-LA Casenote Audit Proforma. Key Results: INSERT YOUR RESULTS SHEET HERE Actions and Recommendations: INSERT YOUR ACTION PLAN DOCUMENT HERE Page 23 of 25

24 Recommendations and Action Plan: Please list all recommendations from the results and give a summary of the action plan developed to implement the recommendations. 1. Recommendation Action Timescale Person responsible for implementation Please continue on a separate sheet if necessary. Page 24 of 25

25 Continuation Sheet (if necessary) Page 25 of 25

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