CHMRAT Roll Out th February 2013 Practice Support and Development Officer GNC

Community Health Medical Record Audit Tool CHMRAT

This Audit tool has been developed as a Standardised Community Health Medical Record Audit tool to be used by all HNE services who use CHIME. Health Care Record Auditing is required by the NSW Health PD Health Care Records Documentation and Management PD 2012_069 It will provide your services with supporting evidence required for EQuIP National Accreditation. Introduction

Staff employed by HNELHD have a responsibility for ensuring Health records are maintained and managed in accordance with: –Medico-legal requirements –NSW Health Policy – refer to Help Guide pg 9 –LHD Procedures and Guidelines Responsibilities and Accountabilities

Clinical audits of documentation in health care records are to have a Team based approach. Results are to be: Provided to relevant clinical areas and health care personnel Included in the HNELHD performance reports Referred to the HNELHD quality committees to facilitate quality improvement

To adhere to the use or disclosure of health information for the management of health services in accordance with the Health Records and Information Privacy Act 2002 (NSW) Statutory guidelines on the management of health services To select medical records for auditing without bias Provide audit results to the line manager/service manager in accordance with pre determined time frames Report immediately any non compliance below 90 % Auditors Responsibilities

Help guide ( separate document to the audit tool) First two tabs – ‘Auditors’ and ‘Instructions’ Top and bottom of each Assessment tab Criteria with a red triangle indicate pop-up comment or further instructions attached –Mouse over criteria cell to view pop-up comment Instructions can be Found:

Selecting Records to Audit Simple random selection At least 10 records per team/program/site Run CHIME report “Clients Discharged” Records must contain documentation from within the past six months See help guide for further instructions on selecting sample for long term clients on active service

Suggestions for Conducting the Audit Allocate 4-6 hours to complete first audit Where possible relieve auditor from normal duties - eg Admin from front desk duties Use of two screens, or side by side computers facilitates the audit process –One screen for audit tool, one for iPM/CHIME

First 2 tabs – Instructions Next 18 tabs – Six Coloured Categories 1.Assessment Auditors 2.Action Plan Manager 3.Graph Manager Summary Manager Report Manager Audit Tool - 22 Tabs

Six Categories

Auditors

Multiple auditors will be completing this document Save on a sharedrive accessible by all auditors ALL auditors to complete SAME copy of audit tool Must name the document: YYYY MMM - Cluster name - service name - CHMRAT.xlxs Saving the Audit

Assessment Tabs Location, Service, Date and Auditor Information MRNs and Service Request IDs Criteria Yes / No / n/a Comments

When the Audit tool has: 10 records audited in assessment tabs Service manager has completed all action plans and report tab the completed and correctly named document to the designated CHMRAT Coordinator for your cluster Completed Audit

Reporting Results Summary tab results reported : At a local level for quality improvement At a cluster level for benchmarking At an area level for educational and planning purposes Report tab presented at Quality and Patient Care Committee or Risk management meeting

CHMRAT Any Questions or feedback Should be provided to your CHMRAT Audit Coordinator