Documentation Auditing

Policy

Category:  Clinical Services
Subject:  Documentation Auditing
Division: Community Health and Wellness 
Policy Number:  CA.72.01.105
Effective Date:  October 26, 2017

POLICY STATEMENT

Documentation auditing involves checking for compliance to a standard, policy requirement or guideline. It consists of examining a sample of documentation to identify any gaps between practices and meeting professional standards, policies or guidelines.

As per Wellington-Dufferin-Guelph Public Health’s policy CA.50.01.101 Documentation Practices, it is each program’s responsibility to implement an auditing practice for documentation.

The purpose of this policy is to ensure that documentation complies with specified requirements and standards of practice using an audit tool within the Clinical Services program. This will assist in improving documentation practices, enhancing the quality of client care. 

The Audit tool was developed to assist auditor’s (public health nurses selected from Clinical Services) to assess compliance and provide a method of feedback to staff and management in order to improve the quality of documentation. Auditing is not a form of performance appraisal rather a method to encourage consistent program documentation.

All Clinical Services staff will participate in the peer auditing process as outlined in the corresponding procedure CA.72.02.105 Documentation Auditing

SCOPE

This policy applies to all WDGPH nurses assigned to Clinical Services and student nurses working in these programs.  

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure: CA.72.02.105 Documentation Auditing

CA.50.01.100 and CA.50.02.100 Abbreviations and Acronyms

CA.50.01.101 and CA.50.02.101 Documentation Practices

Clinical Services Chart Audit Tool 

College of Nurses of Ontario, Practice Standard, Documentation

College of Physicians and Surgeons of Ontario, Policy, Medical Records

CONTACT FOR INQUIRIES

Director, Community Health and Wellness

APPROVED BY

Director, Community Health and Wellness


Procedure

Category:  Clinical Services
Subject:  Documentation Auditing
Division: Community Health and Wellness 
Procedure Number:  CA.72.02.105
Effective Date:  October 26, 2017

PROCEDURE

An audit committee consisting of public health nurses (PHNs) within the Clinical Services program will review client health records at a minimum of every three months to ensure compliance with professional standards and Agency policy. 

Audits will be conducted by program staff on a rotational basis.

Client health records will be selected at random but will include clients visiting all locations (including outreach locations) and will include a variety of appointment types (immunization, travel health and sexual health). Auditors will document how they select client charts at random.

Audits will be conducted using the program specific audit tool and a report of audit finding will be recorded on the chart audit summary tool.

This chart audit summary tool will be sent to the Manager, Clinical Services and the Chief Nursing Officer. If there are any critical/recurring errors then the manager will follow-up as required. 

The findings of the audit will be reviewed at the next team meeting.

Completed audit tools and summaries will be retained for a period of seven years. 

RESPONSIBILITIES

Management will:

  • Ensure chart auditing occurs according to program policy; and
  • Ensure a PHN(s) is assigned for chart auditing and is familiar with the chart auditing tools.

Employees will:

  • Review documents supporting documentation practice;
  • Review chart auditing tools;
  • Rotate role as auditor.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy CA.72.01.105 Documentation Audit

CA.50.01.101 and CA.50.02.101 Documentation Practices

CA.50.01.100 and CA.50.02.100 Abbreviations and Acronyms

Clinical Services Chart Audit Tool 

College of Nurses of Ontario, Practice Standard, Documentation

College of Physicians and Surgeons of Ontario, Policy, Medical Records

CONTACT FOR INQUIRIES

Director, Community Health and Wellness

APPROVED BY

Director, Community Health and Wellness