1.9.2 The design of the patient clinical record allows for systematic audit of the C contents against the requirements of these Standards 1.18 Implementing processes to enable partnership with 1.18.2 Mechanisms are in place to monitor and improve documentation of C patients in decisions about their care, including informed informed consent consent to treatment 4.6 The clinical workforce taking an accurate medication 4.6.1 A best possible medication history is documented for each patient C history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care 4.7 The clinical workforce documenting the patient’s 4.7.1 Known medication allergies and adverse drug reactions are documented C previously known adverse drug reactions on initial in the patient clinical record presentation and updating this if an adverse reaction to a medicine occurs during the episode of care 4.8 The clinical workforce reviewing the patient’s current 4.8.1 Current medicines are documented and reconciled at admission and N/A medication orders against their medication history and transfer of care between healthcare settings prescriber’s medication plan, and reconciling any discrepancies 4.14 Developing a medication management plan in 4.14.1 An agreed medication management plan is documented and available in N/A partnership with patients and carers the patient’s clinical record 7: Summary of actions that require data collection for audit or review This table identifies which of the NSQHS Standards require clinical audits to be undertaken by dental practices or services. KEY: C= Core action D= Developmental action N/A= Non applicable C/D Agreed and documented clinical guidelines and/or pathways are available C 1.7.1 to the clinical workforce
1.9.2 The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards C 1.18 Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment 1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent C 4.6 The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care 4.6.1 A best possible medication history is documented for each patient C 4.7 The clinical workforce documenting the patient’s previously known adverse drug reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care 4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record C 4.8 The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies 4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings N/A 4.14 Developing a medication management plan in partnership with patients and carers 4.14.1 An agreed medication management plan is documented and available in the patient’s clinical record N/A 7: Summary of actions that require data collection for audit or review This table identifies which of the NSQHS Standards require clinical audits to be undertaken by dental practices or services. KEY: C= Core action D= Developmental action N/A= Non applicable C/D 1.7.1 Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce C
NSQHS-Standards-Guide-for-Dental-Practices.docx