children s physiotherapy records audit report 2014 · (3) childrens physiotherapy records audit...

Children’s Physiotherapy

Records Audit Report

2014

(3) Childrens Physiotherapy Records Audit Report 2013 1

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


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


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

Criteria

Records sourced from active caseloads from within the last three months from date of start of audit.

Methodology

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

Results

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


Section F – additional Questions specific to Service/Team

Section A: Patient Identification

Section A: Patient ID 1 Yes No N/A

Q1 NHS Number (clearly & correctly documented)

92.9% (N=26) 7.1% (N=2) 0.0% (N=0)

Q2 Forename (clearly & correctly documented)

100.0% (N=28) 0.0% (N=0) 0.0% (N=0)

Q3 Surname (clearly & correctly documented)

100.0% (N=28) 0.0% (N=0) 0.0% (N=0)

Q4 Date of Birth (clearly & correctly documented)

100.0% (N=28) 0.0% (N=0) 0.0% (N=0)

Q5 Patient Number (i.e. any other relevant identification nu... 92.9% (N=26) 0.0% (N=0) 7.1% (N=2)

Q6 Apart from the above, are there any other personal detail... 3.6% (N=1)

96.4% (N=27)

0.0% (N=0)

Section A: Patient ID 2 Yes No N/A

Q7 Patient contact details (Address, telephone number)

96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q8 Is the patient’s gender recorded? 82.1% (N=23)

17.9% (N=5)

0.0% (N=0)

Q9 Is the patient’s ethnicity recorded? 89.3% (N=25)

10.7% (N=3)

0.0% (N=0)

Q10 Are other relevant contact details recorded in the record (e.g. Next of Kin, Carers, Lasting Power of Attorney)?

78.6% (N=22)

21.4% (N=6)

0.0% (N=0)

Q11 Where applicable, are the patient details recorded in the

96.4% (N=27)

0.0% (N=0)

3.6% (N=1)


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:

Administration error for recording of gender

Individual members of staff to record ethnicity and parent/carer detail

Section B: Health Care Professional Identification

Section B Health Care Professionals ID Yes No N/A

Q13 Signed (identifiable signature) 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q14 Printed Full Name 92.9% (N=26)

7.1% (N=2)

0.0% (N=0)

Q15 Designation of staff in record or on signature list in record.

96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q16 Are all student entries countersigned by a qualified/ supervising staff member?

0.0% (N=0)

0.0% (N=0)

100.0% (N=28)

Comments on Section B:

13 Q13 All good


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

Section C: Records and Notes

Section C: Records/Notes 1 Yes No N/A

Q18 Are the records correctly filed (secure/safe location and...

100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q19 Is there a record tracing/tracking system in place?

0.0% (N=0)

100.0% (N=28)

0.0% (N=0)

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)

3.6% (N=1)

0.0% (N=0)

Q21 Is the patient’s name on every page? 75.0% (N=21)

25.0% (N=7)

0.0% (N=0)

Section C: Records/Notes 2 Yes No N/A

Q22 Is the patient's NHS number on every page?

67.9% (N=19)

32.1% (N=9) 0.0% (N=0)

Q23 Are the record contents in chronological order?

100.0% (N=28)

0.0% (N=0) 0.0% (N=0)

Q24 Do all the records in the folder belong to the correct patient?

100.0% (N=28)

0.0% (N=0) 0.0% (N=0)

Q25 Is there a Medicine Log or Prescription Card in the records?

3.6% (N=1)

0.0% (N=0) 96.4% (N=27)

Q26 Are all papers filed securely in the notes? (i.e. nothing loose)

78.6% (N=22)

21.4% (N=6) 0.0% (N=0)


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:

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

Section D: Case Note Entries 1 Yes No N/A

Q28 Dated (day, month, year) 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q29 Timed (hour and minute, 24hr clock or am/pm specified)

32.1% (N=9)

67.9% (N=19)

0.0% (N=0)

Q30 Are the entries in the record consecutive? 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q31 Are continuation sheets numbered? 89.3% (N=25)

10.7% (N=3)

0.0% (N=0)

Q32 Are the entries in the record clearly written? 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q33 Are the entries made in permanent ink and readable when photocopied?

100.0% (N=28)

0.0% (N=0)

0.0% (N=0)


Q34 Are there any abbreviations in the last entry? 78.6% (N=22)

21.4% (N=6)

0.0% (N=0)

Section D: Case notes Entries 2 Yes No N/A

Q35 If Yes, is the abbreviation written in full at first entry?

13.6% (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 abbreviations in the record?

89.3% (N=25)

10.7% (N=3)

0.0% (N=0)

Q38 Are any alterations readable, dated, timed and signed?

66.7% (N=6)

33.3% (N=3)

0.0% (N=0)


Q39 Has any correction fluid been used to make alterations?

11.1% (N=1)

88.9% (N=8)

0.0% (N=0)

Q40 Was appropriate consent obtained and recorded (i.e. written, verbal or implied)?

96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q41 Is the need for a Mental Capacity Act Assessment recorded ? (Note: not applicable to under 16s)

0.0% (N=0)

7.1% (N=2)

92.9% (N=26)

Q42 Have risk assessments been conducted and documented?

3.6% (N=1)

3.6% (N=1)

92.9% (N=26)

Q43 Are there any subjective or offensive statements?

0.0% (N=0)

100.0% (N=28)

0.0% (N=0)



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)

3.6% (N=1)

0.0% (N=0)

Q46 Was there a record made of other people present during the consultation (e.g. chaperone, carer, other healthcare professional)?

82.1% (N=23)

10.7% (N=3)

7.1% (N=2)

Q47 Are the notes written in terms that a patient and/or parent/carer can understand?

78.6% (N=22)

21.4% (N=6)

0.0% (N=0)

Q48 Are the notes written in terms that another professional involved in the care of the patient can understand?

100.0% (N=28)

0.0% (N=0)

0.0% (N=0)


Q49 Do the notes identify problems which have arisen?

92.9% (N=26)

7.1% (N=2)

0.0% (N=0)

Q50 And, is the action taken to rectify them recorded?

89.3% (N=25)

0.0% (N=0)

10.7% (N=3)


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


Omissions and concerns within this section that were highlighted included:


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

Section E: Do the notes Provide Clear Evidence

Section E: Do the notes provide clear evidence of: 1

Yes No N/A

Q52 Assessments carried out? 96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q53 The decisions made? 96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q54 The care planned? 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q55 All required care delivered? 100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Section E: Do the notes provide clear evidence of: 2

Yes No N/A

Q56 The notes having been written with the patient and / or parent / carer e.g. in discussions about assessment / plan / outcome?

100.0% (N=28)

0.0% (N=0)

0.0% (N=0)

Q57 The information/leaflets shared with patient and/ or parent / carer?

46.4% (N=13)

7.1% (N=2)

46.4% (N=13)


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

Section F – Additional questions specific to Service / Team

Section F: Additional Questions specific to Service/Team: 1

Yes No N/A

Q59 Are all correspondence filed in date order, most recent on top?

96.4% (N=27)

0.0% (N=0)

3.6% (N=1)

Q60 Are copy correspondence photocopies (incl. signature) of the originals sent out?

75.0% (N=21)

7.1% (N=2)

17.9% (N=5)

Q61 Where applicable, is consent to share information recorded?

85.7% (N=24)

7.1% (N=2)

7.1% (N=2)

Q62 Details recorded of information shared and with whom?

60.7% (N=17)

3.6% (N=1)

35.7% (N=10)

Q63 Are the reasons for sharing information recorded?

42.9% (N=12)

17.9% (N=5)

39.3% (N=11)

Q64 If applicable, has the child/young person’s competence been assessed and recorded in line with Fraser Guidelines?

0.0% (N=0)

14.3% (N=4)

85.7% (N=24)

Q65 Is a Significant Life Events Sheet being used? 0.0% (N=0)

21.4% (N=6)

78.6% (N=22)

Section F: Additional Questions specific to Service/Team: 2

Yes No N/A


Q66 If applicable are there copies of case conference minutes in the record?

10.7% (N=3)

10.7% (N=3)

78.6% (N=22)

Q67 If applicable, are there Core Group meeting minutes in the record?

7.1% (N=2)

3.6% (N=1)

89.3% (N=25)

Q68 If applicable is relevant child protection supervision recorded in the notes?

3.6% (N=1)

10.7% (N=3)

85.7% (N=24)

Q69 Are copies of referrals to Social Care included? 3.6% (N=1)

10.7% (N=3)

85.7% (N=24)

Q70 Is an EKOS form filed in the notes? 96.4% (N=27)

3.6% (N=1)

0.0% (N=0)

Q71 Is the EKOS form completed and updated? 39.3% (N=11)

60.7% (N=17)

0.0% (N=0)

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.


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


71 Q71 17 files did not have a completed or up to date EKOS form

Within this section it was identified that:


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

Section A: 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.

Section B: Health Care Professional Identification

Good compliance with the audit requirements

Section C: Records and Notes

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.


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.


Section E: Do the notes Provide Clear Evidence

Section F: Additional questions specific to Service / 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.


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

Time of appointments

Signing of letters before filing

Recording the reason for sharing information with a specified person

Securing all paper work in files

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

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


No Key Findings Recommendations/Actions Required Staff Member Responsible

Timescales / Implementation Date

Staff to have feedback on the audit to highlight incorrect use of abbreviations

IJ and JA July 2014

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

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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


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Record Audit Ref:

_ _ _ _ _ _ _ _ _

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

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)


20

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)


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


21

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?

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 / 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


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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) 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: ….... /…..…. /………..

Based on Shropshire Community Health NHS Trust Clinical Record Keeping Form Template V7 – Jun 2012


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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.

http://www.shropscommunityhealth.nhs.uk/content/page/20274/physiotherapyrecordkeepingaudit.htm

http://www.shropscommunityhealth.nhs.uk/content/page/20274/physiotherapyrecordkeepingaudit.htm

children s physiotherapy records audit report 2014 · (3) childrens physiotherapy records audit...

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