Audit Tips for Clinical Documentation
Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents include:
- Age Related Residential Care (ARRC) contract
- NZS 8134:2008 Health and Disability Services Standards
- Clinical best practice (EBP) guidelines – eg; Lippincott
- The Code of Health & Disability Consumers Services Rights 1996
Clinical documentation errors of any type noted during audits will result in partial attainments at best. This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.
Below are some of the common compliance gaps which relate to clinical documentation:
| General compliance
gaps |
Missed signatures off notations. Not dated. Not signed by the author with a full signature. No designation written with signature. Not legible. Inconsistent structure of resident files. Unclear or unsecured archiving of documents. Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing. |
| Initial assessments
including InterRai |
Not completed within time-frames defined in ARRC. Baseline recordings at time of admission not recorded. Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions. Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments. Failure to re-assess for each period of admission eg; respite care. |
| Clinical risk |
Assessment not describing risk. Risk not reflected in care plan interventions. Lack of risk reviews. Level of risk noted in interRai assessments not included in care planning |
| Progress notes |
Not recorded in on a shift by shift basis. Lack evidence of regular registered nurse input. Writing beyond the bottom line of the page. Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well). Lack evidence of interventions being implemented. Lack evidence of RN response to clinical symptoms reported by care staff. Lack of evidence of rationale for PRN medication administration or the resulting effect. |
| Short Term
Care Plans |
Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness). 24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours). Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse. Not recorded as resolved or transferred to Long Term Care Plan. Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes. |
| Long Term
Care Plan (LTCP) |
Not reflective of all presenting potential and actual medical / clinical problems. Not documented within 3 weeks of the date of admission (ARRC requirement). Not changed at the time of health status / functional change. Interventions not reflective of each medical diagnosis. Interventions not changed within LTCP to reflect changes recorded in care plan evaluations. Frequency of clinical assessment for each actual clinical presentation eg; pain. Do not clearly indicate the level of function, assistance required for each component of care / support. Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services for the elderly etc. |
| Care Plan
Evaluations |
Review of care plans not reflecting changes in residents health status as they occur. Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation. Not completed within ARRC defined time-frames (at least six monthly). |
| Multi-Disciplinary
Input |
Lack evidence of MDT input into care plan reviews and/or evaluations. Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning. Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian. Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical consultation notes however not evidenced as having been done. Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc. |
| Policy and
procedures |
Not consistent with service delivery as noted in clinical documentation. |
Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.
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