Title Page
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Department/Division
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Healthcare Facility
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Reviewed by
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Conducted on
Medical Audit Checklist
Patient Record System
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All clinical information is recorded electronically, password protected and reliably backed up.
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Patient records are electronic, secure and traceable.
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Clinical notes are dated and reliably identify the author.
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Basic demographic information is sufficient to allow for patient identification and to meet national enrolment requirements.
Medical Record Review
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The record is appropriate, contemporaneous and sources are identified.
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Notes are completed as soon as possible after contact, and any delay is identifiable.
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Information is recorded objectively and does not contain inappropriate, judgmental comment.
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When information is provided other than by the patient, the source is identified.
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Clinical notes can be understood by someone not working regularly at the practice.
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The notes are logical, intelligible and sequential.
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The use of keywords or templates does not compromise the validity of the notes.
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Important background issues, warnings and alerts are displayed for all records.
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Past medical history is available.
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Significant social history is included.
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The PMS is used to effectively display important warnings, and alerts.
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Allergies or the absence of known allergies is recorded for each patient.
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Specific patient needs and instructions are recorded and are available in easily accessible form at the clinically relevant point.
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Patient needs recorded include any directives by patient, disabilities, drug dependencies, end of life and special needs (eg communication, mental health issues).
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The recorded history is relevant and sufficient for both safe management and evidential purposes.
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The reason(s) for the encounter recorded or apparent from the notes.
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The record includes date, place of consultation (if different from usual) and mode of contact if not face to face.
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The record includes all findings essential to diagnosis and management.
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Sufficient positive and negative history and examination findings are present to justify management decisions.
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Objective measurements (BP, pulse, temp., respiratory rate, PaO2 etc) are recorded, where relevant.
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The working diagnosis/differential or problem being managed is apparent and consistent with supporting information.
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The diagnosis (and any differential) and level of certainty is clear from the notes.
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The patient management plan is clear and identifies and addresses uncertainty and conjecture.
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The plan for care can be identified from the record.
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Important assumptions and remaining uncertainties in diagnosis and management are noted.
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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.
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The record supports adequate consenting processes.
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All important clinical decisions and interventions are recorded.
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Treatment plans, including interventions, contingency plans, safety netting and follow-up arrangements are recorded as necessary.
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Clinical management decisions made outside consultations (eg telephone calls) and off-site contacts (home visit, aged care facilities etc) are recorded.
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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.
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Medications initiated or changed outside the practice are reconciled with the PMS.
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Current and long-term medications are differentiated and the status is clear.
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Where long-term medications are changed, reasons for alteration or discontinuation are clear.
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The record identifies all investigations requested and tracks high-risk tests.
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All requests for tests and investigations are recorded.
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High-risk tests (eg histology, cervical smears) are tracked for completion.
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The record supports effective and timely referral for treatment or transfer of care.
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The record shows that referrals are completed within a reasonable time frame.
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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.
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Referrals include urgency, reason/expectation of referral, relevant findings, classifications, warnings and current treatment.
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The transfer of responsibility for care can be verified from the records.
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Follow-up of test results is clearly documented and actions recorded.
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Follow-up actions on test results and referrals are recorded.
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Screening history and results (or declined screening) are recorded.
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Screening history and results (including declines) are evident for routine screening areas (eg cervical smears, mammograms, cardiovascular risk assessment, diabetes screening).
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Screening recall status can be easily tracked.
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There is evidence of patient risk assessment and opportunistic screening for high-risk conditions.
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Immunisation history and status is recorded.
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There is evidence that recommended immunizations are provided in accordance with the national schedule.
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Records show advice given and immunization status for non-scheduled immunizations.
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There is a systematic record of individual risk factors.
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Diseases are classified for chronic conditions, including all conditions for which the patient is on long-term treatment.
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Family history for major risk factors, such as diabetes, early CVD, bowel and breast cancer etc.
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Current employment (where relevant) and any history of at-risk occupations.
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Blood pressure monitoring as clinically indicated.
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Baseline weight/BMI and monitoring as clinically indicated.
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Smoking status and history and cessation support offered, where relevant.
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Alcohol and drug usage.
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Regular review of chronic conditions as per current best practice (eg INR, diabetes, CVR).
Completion
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Additional Recommendations
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Reviewer Name & Signature
Multidisciplinary Team
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Name, Department & Signature
