Title Page

  • Department/Division

  • Healthcare Facility
  • Reviewed by

  • Conducted on

Medical Audit Checklist

Patient Record System

  • All clinical information is recorded electronically, password protected and reliably backed up.

  • Patient records are electronic, secure and traceable.

  • Clinical notes are dated and reliably identify the author.

  • Basic demographic information is sufficient to allow for patient identification and to meet national enrolment requirements.

Medical Record Review

  • The record is appropriate, contemporaneous and sources are identified.

  • Notes are completed as soon as possible after contact, and any delay is identifiable.

  • Information is recorded objectively and does not contain inappropriate, judgmental comment.

  • When information is provided other than by the patient, the source is identified.

  • Clinical notes can be understood by someone not working regularly at the practice.

  • The notes are logical, intelligible and sequential.

  • The use of keywords or templates does not compromise the validity of the notes.

  • Important background issues, warnings and alerts are displayed for all records.

  • Past medical history is available.

  • Significant social history is included.

  • The PMS is used to effectively display important warnings, and alerts.

  • Allergies or the absence of known allergies is recorded for each patient.

  • Specific patient needs and instructions are recorded and are available in easily accessible form at the clinically relevant point.

  • Patient needs recorded include any directives by patient, disabilities, drug dependencies, end of life and special needs (eg communication, mental health issues).

  • The recorded history is relevant and sufficient for both safe management and evidential purposes.

  • The reason(s) for the encounter recorded or apparent from the notes.

  • The record includes date, place of consultation (if different from usual) and mode of contact if not face to face.

  • The record includes all findings essential to diagnosis and management.

  • Sufficient positive and negative history and examination findings are present to justify management decisions.

  • Objective measurements (BP, pulse, temp., respiratory rate, PaO2 etc) are recorded, where relevant.

  • The working diagnosis/differential or problem being managed is apparent and consistent with supporting information.

  • The diagnosis (and any differential) and level of certainty is clear from the notes.

  • The patient management plan is clear and identifies and addresses uncertainty and conjecture.

  • The plan for care can be identified from the record.

  • Important assumptions and remaining uncertainties in diagnosis and management are noted.

  • The record identifies information given to the patient, including risks and benefits of treatments and, where relevant,
    consent.

  • Notification of test results and clinical findings is recorded.

  • The record supports adequate consenting processes.

  • All important clinical decisions and interventions are recorded.

  • Treatment plans, including interventions, contingency plans, safety netting and follow-up arrangements are recorded as necessary.

  • Clinical management decisions made outside consultations (eg telephone calls) and off-site contacts (home visit, aged care facilities etc) are recorded.

  • The record identifies all medication treatment provided, including the type, dosage and total amount of any
    medications prescribed.

  • There is a record of all prescriptions issued, including drug name, administration instructions and quantities ordered.

  • Medications initiated or changed outside the practice are reconciled with the PMS.

  • Current and long-term medications are differentiated and the status is clear.

  • Where long-term medications are changed, reasons for alteration or discontinuation are clear.

  • The record identifies all investigations requested and tracks high-risk tests.

  • All requests for tests and investigations are recorded.

  • High-risk tests (eg histology, cervical smears) are tracked for completion.

  • The record supports effective and timely referral for treatment or transfer of care.

  • The record shows that referrals are completed within a reasonable time frame.

  • Copies of referral letters to and from the practice, certifications, referrals and responses, discharge summaries and test results are included in the patient PMS record or accessibly filed.

  • Referrals include urgency, reason/expectation of referral, relevant findings, classifications, warnings and current treatment.

  • The transfer of responsibility for care can be verified from the records.

  • Follow-up of test results is clearly documented and actions recorded.

  • Follow-up actions on test results and referrals are recorded.

  • Screening history and results (or declined screening) are recorded.

  • Screening history and results (including declines) are evident for routine screening areas (eg cervical smears, mammograms, cardiovascular risk assessment, diabetes screening).

  • Screening recall status can be easily tracked.

  • There is evidence of patient risk assessment and opportunistic screening for high-risk conditions.

  • Immunisation history and status is recorded.

  • There is evidence that recommended immunizations are provided in accordance with the national schedule.

  • Records show advice given and immunization status for non-scheduled immunizations.

  • There is a systematic record of individual risk factors.

  • Diseases are classified for chronic conditions, including all conditions for which the patient is on long-term treatment.

  • Family history for major risk factors, such as diabetes, early CVD, bowel and breast cancer etc.

  • Current employment (where relevant) and any history of at-risk occupations.

  • Blood pressure monitoring as clinically indicated.

  • Baseline weight/BMI and monitoring as clinically indicated.

  • Smoking status and history and cessation support offered, where relevant.

  • Alcohol and drug usage.

  • Regular review of chronic conditions as per current best practice (eg INR, diabetes, CVR).

Completion

  • Additional Recommendations

  • Reviewer Name & Signature

  • Multidisciplinary Team
  • Name, Department & Signature

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