Children’s Physiotherapy Records Audit Report 2014
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
(3) Childrens Physiotherapy Records Audit Report 2013 2
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 3
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
(3) Childrens Physiotherapy Records Audit Report 2013 4
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)
(3) Childrens Physiotherapy Records Audit Report 2013 5
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
(3) Childrens Physiotherapy Records Audit Report 2013 6
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)
(3) Childrens Physiotherapy Records Audit Report 2013 7
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)
(3) Childrens Physiotherapy Records Audit Report 2013 8
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)
Section D: Case notes Entries 3 Yes No N/A
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)
(3) Childrens Physiotherapy Records Audit Report 2013 9
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)
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)
Section D: Case notes Entries 5 Yes No N/A
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)
(3) Childrens Physiotherapy Records Audit Report 2013 10
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 11
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)
(3) Childrens Physiotherapy Records Audit Report 2013 12
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
(3) Childrens Physiotherapy Records Audit Report 2013 13
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.
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 14
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.
Section D: Case Note Entries
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 15
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.
(3) Childrens Physiotherapy Records Audit Report 2013 16
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
(3) Childrens Physiotherapy Records Audit Report 2013 17
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
18
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
19
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)
(3) Childrens Physiotherapy Records Audit Report 2013
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)
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
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
(3) Childrens Physiotherapy Records Audit Report 2013
22
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
(3) Childrens Physiotherapy Records Audit Report 2013
23
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.