"Audit report form"
Contraceptive implant fitting and removal LES 06 Audit and monitoring form 2010-11, covering the period from 1 April 2010 to 31 March 2011. FOR INFORMATION ONLY – DO NOT USE THIS FORM TO SUBMIT YOUR REPORT Practice/Senior Partner: Name of person completing this form: Email contact for this LES: PAYMENTS are per insertion and removal. Volume of activity between 1 APRIL 2010 – 31 MARCH 2011: 1a) Number of patients fitted with a contraceptive implant during = the reporting period, registered with your practice 1b) Number of patients fitted with a contraceptive implant during = the reporting period, registered with other practices NB See additional detail on page 3 1c) Total number of patients fitted with a contraceptive implant = during the reporting period 2a) Number of patients whose implants have been removed during = the reporting period, registered with your practice 2b) Number of patients whose implants have been removed during = the reporting period, registered with other practices NB See additional detail on page 3 2c) Total number of patients whose implants have been removed = during the reporting period 3) Number of referrals from other practices where the patient = was seen, the procedure was unsuitable and a 50% payment is claimed NB The PCT may carry out a check on a sample of records for post payment verification purposes Page 1 of 3 4) Referrals from other practices: detailed information Referring practice, Number of referrals from Number of Reasons why these by senior partner or each practice to your inappropriate referrals were surgery name: practice for this referrals from inappropriate: Enhanced Service: each practice: please specify whether for insertion or removal of implants Please continue on a separate sheet if necessary. Page 2 of 3 Please attach a report for any significant events related to this Enhanced Service during 2010-11, using the PCT proforma. We will assume that you are willing to share anonymised information about significant events, for shared learning, unless your report clearly states otherwise. What changes do you plan to implement, if your Who will be When will the results need improvement? responsible? action be completed? Have you any comments on the development of this service? Recommended Read codes: 5 byte Version 3 Insertion of subcutaneous Insertion of subcutaneous contraceptive 7G2AB contraceptive 7G2AB Removal of subcutaneous Removal of subcutaneous contraceptive 7G2H7 contraceptive Xa85g Additional useful codes: 5 byte Version 3 Counselling for contraceptive 677D Counselling for contraceptive 677D implant implant Check of subcutaneous 61KB Check of subcutaneous 61KB contraceptive* contraceptive* *annual check not required in LES specification Page 3 of 3