Record Keeping Audit Template by lld99380

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									 Policy Document Control Page

 Title: Record Keeping Audit Procedure

 Version: 2

 Reference Number: CL60


 Supersedes: Version 1

 Description of Amendment(s): Updated Section 3: Criteria and Method to reflect updated
 policies. Updated Appendix A to reflect 2009/2010. Changed logo and text to Foundation
 Trusts.


 Originated By: Reagan Blyth

 Designation: Clinical Effectiveness Manager



 Equality Relevance Assessment Undertaken by: Policy currently going through EIA
 Process

 ERA undertaken on:

 ERA approved by EIA Work group on:

 Where policy deemed relevant to equality-

 EIA undertaken by

 EIA undertaken on

 EIA approved by EIA work group on




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Record Keeping Audit Procedure v2
 Referred for approval by: Clinical Information Governance Committee

 Date of Referral: 5th October 2009

 Approved by: Clinical Information Governance Committee

 Approval Date: 5th October 2009

 Date Ratified at IGG: 13/10/09

 Executive Director Lead: Dr S Kaligotla, Medical Director


 Issue Date: 21/10/09

 Circulated by: Corporate Governance

 Issued to: Chief Executive
            Director of Finance
            Director of Operations
            Director of Nursing and Organisational Development
            Medical Director


 Policy to be uploaded to the Trust’s External Website? YES


 Review Date: October 2010

 Responsibility of: Reagan Blyth

 Designation: Clinical Effectiveness Manager


 An e-copy of this policy is sent to all wards and departments (Trust Policy Pack Holders)
 who are responsible for updating their policy packs as required.

 This policy is to be disseminated to all relevant staff.

 This policy must be posted on the Intranet.

 Date posted:21/10/09




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Record Keeping Audit Procedure v2
              Record Keeping Audit Procedure




                     Clinical Audit Department




                                    Contents
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Record Keeping Audit Procedure v2
                                                Page

   1. Introduction                               5




   2. Duties                                     5




   3. Criteria and method                        6




   4. Frequency                                  8




   5. Content of reports                         8




   6. Action plan                                8



   7. Monitoring effectiveness                   9



   8. Evaluation and review                      9



   9. Appendix A (Audit proforma for 2009/10)    10




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Record Keeping Audit Procedure v2
1. Introduction
Pennine Care NHS Foundation Trust’s Records Management Policy states that our
organisation’s records are our corporate memory, providing evidence of actions and
decisions and representing a vital asset to support our daily functions and operations. They
support policy formation and managerial decision making, protect the interests of Pennine
Care NHS Foundation Trust and the rights of patients, staff and members of the public who
have dealings with the Trust. They support consistency, continuity, efficiency and
productivity and help us to deliver our services in consistent and equitable ways.

All NHS records are public records under the Public Records Acts and must be kept in
accordance with the following statutory, Government and NHS guidelines:

• Public Records Acts 1958 and 1967
• Data Protection Act 1998
• Freedom of Information Act 2000
• Records Management: NHS Code of Practice 2006
• Lord Chancellor’s Code of Practice on the management of records under Section 46 of the
Freedom of Information Act 2000

Pennine Care NHS Foundation Trust undertakes a regular record keeping audit to evaluate
practice and promote high standards of casenote documentation. The aim of this document,
the Record Keeping Audit Procedure, is to set out how the regular record keeping audit will
be conducted.

Clinical audit is a key element of clinical governance and aims to improve care, treatment
and services for patients. The process involves measuring whether care and treatment is
provided in accordance with national and local agreed standards. By assessing and
evaluating care via clinical audit projects, areas for improvement can be identified and
suitable improvement plans developed and implemented. Clinical audit of record keeping
therefore aims to continually improve the quality of the casenotes held by Pennine Care NHS
Foundation Trust and to reduce the risks associated with the quality of written clinical records

2. Duties
2.1 Medical Director
The Medical Director is the Executive Director responsible for the quality of written records
and is the chair of the Clinical Information Governance Committee.

2.2 Clinical Information Governance Committee
The Clinical Information Governance Committee is responsible for the selection of services
for the Trust record keeping audit. The Clinical Information Governance Committee is also
responsible for the review of results for this audit and the subsequent development and
monitoring of action plans.

2.3 Research and Audit Panel
The Research and Clinical Audit Panel is chaired by the Trust’s Medical Director and is
responsible for the review and approval of all audits proposed within the Trust, including
record keeping audits.


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Record Keeping Audit Procedure v2
2.4 The Clinical Audit Department
The Clinical Audit Department will assist in the co-ordination of the Trust record keeping audit
including proforma design, review of criteria, analysis of data, report writing and presentation
of findings.

2.5 Service Managers
Service Managers are responsible for ensuring written documentation is checked within
clinical casenotes and for maintaining quality of record keeping for that service. Service
Managers should also ensure implementation of action plans from local record keeping
audits and from the Trust record keeping audit.

2.6 Clinical staff
Clinical staff are required to participate in regular service evaluation and clinical audit,
including the Trust record keeping audit. All staff who contribute to the written clinical record
should take part in regular audit of record keeping. In addition to the Trust wide record
keeping audit staff may also undertake further record keeping audits at department, service
or locality level. The criteria in section 3 of this procedure should be used for all record
keeping audits.

Staff from the services selected for the Trust record keeping audit will be involved in the peer
review of written records and data collection.


3. Criteria and Method
The audit criteria are based upon good practice/guidelines from the following:

   -   Pennine Care NHS Foundation Trust Records Management Policy: Version 4, issued
       on July 31st 2008.
   -   Pennine Care NHS Foundation Trust Medicines Policy: Version 4, issued on August
       6th 2008.
   -   Pennine Care NHS Foundation Trust Child Safeguarding Policy: Version 2, issued on
       October 2009.
   -   The Code: Standards of conduct, performance and ethics for nurses and midwives,
       Nursing and Midwifery Council, implemented on 1st May 2008.
   -   Record Keeping Advice Sheet, Nursing and Midwifery Council, updated 2007.
   -   Setting the Record Straight – A Review of Progress in Health Records Services, Audit
       Commission. London HMSO, 1999.
   -   Good Medical Practice (2006), General Medical Council.

The criteria used are detailed in the following two tables. The first table contains general
criteria, applicable to all written records. The second table contains criteria that are specific
to inpatient prescription cards / depot cards.

Criteria – General
The last entry in the records is signed
The signature is printed alongside the 1st entry (or in the signature bank)
The designation is printed against the 1st entry (or in the signature bank)
The entry is accurately dated

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Record Keeping Audit Procedure v2
The entry is timed using the 24 hour clock
The entry is written in indelible ink (that cannot be erased)
The entry is legible (is clearly written and can be read without difficulty or ambiguity)
Jargon, meaningless phrases, irrelevant speculation, offensive or subjective statements
are avoided.
Any alterations or additions are dated, timed and signed. The original entry can still be
read clearly.
The RT2 number is on all sheets
The patient name (both first name and surname) is on all sheets
The patient’s NHS number is on all clinical correspondence
It is recorded whether the patient has a child within the family, in the household or cared
for by the patient
The name, address, age, primary carer, GP, school and first name of the child are
recorded.
Records are bound and stored so that loss of documents is minimised
The record is robust (it is in a good state of repair with no tears)
There are no inside pockets or flaps
There are no polypockets in the casenotes
The health record contains clear instructions on the filing of documents (printed on the
inside of the file or on the dividers)
Machine produced recordings are mounted and securely stored
Case notes are not in excess of 10cm thick (as they become unmanageable and should
be split into volumes)
Criteria – Inpatient prescription card / depot card
The patient name is on all sheets
The RT2 number is on all sheets
The NHS number is on all sheets
All prescription and administration entries are signed
All prescription and administration entries are accurately dated
All prescription entries state the time the medicine is to be given
All administration entries state the time the medicine is actually given
The approved or accepted name of the medicine is written in capital letters
The dose is written in metric units, avoiding the use of decimal points
If used, MICROGRAMS is written in full (not abbreviated to mcg)
All entries are in indelible ink (that cannot be erased)
All entries are legible (clearly written and can be read without difficulty or ambiguity)
All prescription and administration entries state the dosage
All prescription and administration entries state the route of administration
Allergies and sensitivities are recorded on the front of the drug chart (or it is recorded that
there are no known allergies)
For re-writes, the date of the original prescription is used
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Record Keeping Audit Procedure v2
The chart has a box to complete when the whole chart is re-written and this is used where
appropriate

The criteria will be measured via retrospective data collection from multi-disciplinary
casenotes, from a minimum of 50% of services across the Trust. The services included in
each audit will be determined by the Clinical Information Governance Committee.
Documented multi-professional entries between a defined time period will be considered. A
data collection proforma will be used, reflecting the above criteria (a copy of the proforma for
2009/10 can be found in Appendix A).


4. Frequency
Where an audit identifies problems or deficiencies an action plan is developed which is
intended to lead to improvements. It would not be appropriate to commence a re-audit
before the action plan has been drawn up and implemented.

The Trust record keeping audit will be repeated one year after the Clinical Information
Governance Committee agrees the action plan in respect of the previous audit. A re-audit
time schedule of one year will allow time for the action plan to be implemented and for
improvements to be made before the re-audit commences.


5. Content of reports
The Trust has an Example Audit Report Template and Guide for Clinical Audit Reports that
provides guidance in respect of the content of audit reports. The record keeping audit report
will be written in accordance with this guidance.

At a minimum the audit report should begin with a background to the audit, a statement
outlining the project aim and a statement of the project objectives (a list of the individual
actions which must be performed in order to achieve the aim). The Trust will adhere to this
guidance for minimum content of the audit report.

In addition, the guidance states that the report should provide details of the method used to
undertake the audit, including details of which cases were reviewed and how the data was
collected.

The full results should be contained within the report in a logical order and for this audit it is
appropriate to also provide a summary to draw out the important and salient results. In
respect of the record keeping audit, a comparison will be made with results of the previous
audit.
The report will then include a conclusion to summarise the implications of the results and will
always include an action plan detailing any action required to lead to improvements.


6. Action plan
Audit should be a quality improvement process. Therefore, having identified
problems or deficiencies in structures, processes or outcomes, an action plan should be
developed to improve record keeping and the quality of written records.
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Record Keeping Audit Procedure v2
The Clinical Information Governance Committee is responsible for the development and
review of action plans in respect of the Trust record keeping audit. For department or service
level audits the respective multi-disciplinary team should plan appropriate action. The action
plan must always include a review date and identify the individual(s) responsible for the
implementation of each action.

The results of the Trust record keeping audit will be presented to the Clinical Information
Governance Committee by the Clinical Audit Department. The action plan will be discussed
and developed at this meeting. It will subsequently be written into the report for final
ratification by the Committee and dissemination to services.

7. Monitoring effectiveness
The Trust record keeping audit will be repeated a year after the Clinical Information
Governance Committee agrees the action plan in respect of the previous audit. Each Trust
record keeping audit will contain a comparison with the results from the previous audit. This
will be an opportunity for the Clinical Information Governance Committee to monitor the
effectiveness of the action plan and determine whether improvements have been made.

In addition, reported incidents in relation to record keeping are monitored quarterly by the
Clinical Information Governance Committee. This will act as another method to review the
effectiveness of action plan(s).

Local service action plans will be reviewed and monitored by the Service Manager and
Locality Manager

8. Evaluation and Review
This procedure document will be reviewed by the Clinical Information Governance
Committee after completion of each Trust record keeping audit (annually). As part of the
review, the Clinical Audit Department will report on the effectiveness of the method and
proforma. This will involve consideration of the completed proformas to identify any
difficulties with data collection / missing data and also feedback from data collectors
regarding the process. A literature search will also be conducted by the Clinical Audit
Department to ensure the criteria are accurate and up to date for the next audit. The main
outcome measure for compliance with the procedure will be fully completed audits illustrating
improvements in record keeping from previous audits.




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Record Keeping Audit Procedure v2
APPENDIX A


Audit ID number:

                     Trust Record Keeping Audit (2009/10)
Complete one form for each set of casenotes.

Locality:
❐ Bury ❐ Child and Adolescent Mental Health Services ❐ Forensic & Specialist Services
❐ Oldham ❐ Rochdale ❐ Stockport           ❐ Substance misuse services        ❐ Tameside


Service:

❐ A&E Liaison                                  ❐ Access & Crisis
❐ Adult Inpatient Services                     ❐ Assertive Outreach
❐ Behavioural Services Team                    ❐ CAMHS
❐ Choices                                      ❐ Community Day Services
❐ Community Mental Health Teams (Adult)        ❐ Community Mental Health Teams (OP)
❐ Complex Cases                                ❐ Crisis Resolution
❐ Counselling service                          ❐ Early Intervention Team
❐ Electroconvulsive Therapy Service            ❐ Employment Services
❐ Tameside Low Secure Unit                     ❐ Rhodes Place Step Down
❐ Stansfield Place Community Rehabilitation    ❐ PICU
❐ Heathfield House Open Rehabilitation Unit    ❐ Buckley Hall Prison Mental Health Service
❐ Specialist Placement Team                    ❐ Intensive Home Treatment Service
❐ Intermediate Care Assessment Team            ❐ Initial Assessment and Intervention
❐ Mentally Disordered Offender Service         ❐ Older People Inpatient
❐ Older Peoples Liaison Service                ❐ Out Patient Clinics
❐ Primary Mental Health Services               ❐ Psychology
❐ Psychological Medicines                      ❐ Drug Liaison Service
❐ Needle Exchange Services                     ❐ Community Drug Team
❐ Community Alcohol Team                       ❐ Therapy Services
❐ Treatment Support Unit


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Record Keeping Audit Procedure v2
Section 1: Case note entries (look at the last entry in the record). All documentation
entries audited must be dated within the last 3 months.

Which professional group made the entry?
❐ Nursing         ❐ Social Worker        ❐ Doctor           ❐ Art Therapist          ❐ Psychologist
❐ Occupational Therapist                 ❐ Other (specify): …………………………………………….

✓ Tick Yes if the last entry complies with the criteria (a blank box will be taken to indicate no).
                                         Criteria                                              Yes

                                                                              Entry signed

                               Signature printed alongside 1st entry (or in signature bank)

                                           1st entry (or signature bank) states designation

                                                                  Entry is accurately dated

                                                             Entry states time (24hr clock)

                                              Entry in indelible ink (that cannot be erased)

             Entry legible (clearly written and may be read without difficulty or ambiguity)

  Jargon, meaningless phrases, irrelevant speculation, offensive / subjective statements
                                                                            are avoided



Section 2: Documentation (look at all records within the last 3 months).
✓ Tick Yes if the last entry complies with the criteria (a blank box will be taken to indicate no).
                                   Criteria                                          Yes       N/A
                                                    RT2 number on all sheets
                                                    Patient name on all sheets
                        - If yes, both first name AND surname on all sheets
                       NHS number included in all clinical correspondence




Continued overleaf
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Record Keeping Audit Procedure v2
Section 3: Child Safeguarding.

Do the records include a period of time when the client first came into contact with the
Pennine Care service?
❐ Yes         ❐ No     (please move to section 4)

✓ Tick Yes if the last entry complies with the criteria (a blank box will be taken to indicate no).
                                   Criteria                                          Yes    N/A
         It is recorded whether the patient has a child within the family, in the
                                         household or cared for by the patient
                          - if there is a child, are the following recorded,
                                                                          - name
                                                                       - address
                                                                            - age
                                                        - name of primary carer
                                                                            - GP
                                                      - school (if of school age)
                                                                 - first language


Section 4: Records / Notes (look at the whole record for the patient).
                                Criteria                                             Yes    N/A
    Records are bound and stored so that loss of documentation is minimised
              The record is robust (it is in a good state of repair with no tears)
                                           There are no inside pockets or flaps
                                        There are NO polypockets in casenote

      The health record contains clear instructions on the filing of documents
                            printed on the inside of the file or on the dividers
          Machine produced recordings are mounted and securely stored.

 Case notes are not in excess of 10cm thick (as they become unmanageable
                                          and should be split into volumes).




Continued overleaf

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Record Keeping Audit Procedure v2
Section 5: Inpatient prescription chart / depot card
All prescription charts / depot cards audited must be dated within the last 3 months. The last
prescription chart / depot card within this time period is to be audited.

Please indicate which was audited: ❐ prescription chart

                                          ❐ depot card
                                          ❐ No prescription chart / depot card for this episode
✓ Tick Yes if applicable (blank box will be taken to indicate ‘No’)
                                    Criteria                                         Yes   N/A
                                                    Patient name on all sheets

                                                     RT2 number on all sheets

                                                    NHS number on all sheets

                         - If yes, both first name AND surname on all sheets

                           All prescription & administration entries are signed

                All prescription & administration entries are accurately dated
                                                           (excluding DEPOTS)
 All prescription entries state time to be given (time circled, or time stated)
                                                        (excluding DEPOTS)
                         All administration entries state time actually given
                                                         (excluding DEPOTS)
         The approved or accepted name of medicine is written in CAPITAL
                                                                LETTERS
                            Dose is in metric units - avoiding decimal points
                              (e.g.125 MICROGRAMS rather than 0.125 mg)
         - If used, MICROGRAMS is written in full (not abbreviated to ‘mcg’)

                             All entries in indelible ink (that cannot be erased)

        All entries legible (clearly written and may be read without difficulty or
                                                                     ambiguity).
                         All prescription & administration entries state dosage

       All prescription & administration entries state route of administration

   Allergies and sensitivities (or No Known Allergies) recorded on front of
                                                                drug chart
             - If Allergies and sensitivities recorded, states what reaction was

                            For re-writes, date of original prescription is used

           Does chart have a box to complete when whole chart is re-written?

     - If chart has a box to complete when whole chart is re-written, - was this
                                                                   completed?

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