Chart type and age of patient Question (iii) Please specify chart type being audited Record the chart type being audited for the patient. Only include charts that are and ‘active’ in current use at the time of audit (that is, do not include charts where all orders have been ceased or have otherwise expired). You may only record one chart type per patient. If the patient has multiple charts in current use, you can audit each chart type separately. Question (iv) The patient is aged 12 or under This question applies to all patients and all types. Record Y if the patient is aged 12 or under. Record N if the patient is aged over 12 Section 1 Patient ID Question 1.1 Patient ID section is completed using (select one option only): Handwritten patient details Printed patient identification labels A mix of printed patient identification labels and handwritten details. Record only one option that applies to all the patient’s active charts. Question 1.2 Patient identification section is completed on all pages of all active charts. Record Y if the Patient ID section has been completed on all pages of all active charts in current use using either a patient ID label or handwritten details. Record N if any Patient ID sections are not complete. Question 1.3 Handwritten patient details are legible and complete (that is, at least 3 patient identifiers documented). This question only applies when either patient details’, or mix of printed ‘handwritten ‘a patient identification labels and handwritten details’ was selected for question 1.1. Record Y if, where handwritten patient details are used, at least three of the following patient identifiers are visible and correct on all pages of the active charts in current use: Medical record number (URN) or Individual Healthcare Identifier Patient name (family name and given names) Date of birth Gender Patient address. Record N if, handwritten patient details are used, two or fewer of the above patient identifiers are visible and correct on one or more of the charts. Question 1.4 Patient’s name is handwritten under patient identification label(s) by first prescriber. This question only applies when either patient identification labels’, or mix of ‘printed ‘a printed patient identification labels and handwritten details’ was selected for question 1.1.
Chart type and age of patient Question (iii) Please specify chart type being audited Record the chart type being audited for the patient. Only include charts that are ‘active’ and in current use at the time of audit (that is, do not include charts where all orders have been ceased or have otherwise expired). You may only record one chart type per patient. If the patient has multiple charts in current use, you can audit each chart type separately. Question (iv) The patient is aged 12 or under This question applies to all patients and all types. Record Y if the patient is aged 12 or under. Record N if the patient is aged over 12 Section 1 Patient ID Question 1.1 Patient ID section is completed using (select one option only): Handwritten patient details Printed patient identification labels A mix of printed patient identification labels and handwritten details. Record only one option that applies to all the patient’s active charts. Question 1.2 Patient identification section is completed on all pages of all active charts. Record Y if the Patient ID section has been completed on all pages of all active charts in current use using either a patient ID label or handwritten details. Record N if any Patient ID sections are not complete. Question 1.3 Handwritten patient details are legible and complete (that is, at least 3 patient identifiers documented). This question only applies when either ‘handwritten patient details’, or ‘a mix of printed patient identification labels and handwritten details’ was selected for question 1.1. Record Y if, where handwritten patient details are used, at least three of the following patient identifiers are visible and correct on all pages of the active charts in current use: Medical record number (URN) or Individual Healthcare Identifier Patient name (family name and given names) Date of birth Gender Patient address. Record N if, handwritten patient details are used, two or fewer of the above patient identifiers are visible and correct on one or more of the charts. Question 1.4 Patient’s name is handwritten under patient identification label(s) by first prescriber. This question only applies when either ‘printed patient identification labels’, or ‘a mix of printed patient identification labels and handwritten details’ was selected for question 1.1.
NSMC-audit-guide-for-hospitals-V1.0-August-2018.docx