4a.5. The clinical record includes Service procedures details of: referring to clinical record The IMP is flexible so that different keeping. goals can be set if the patient’s Case study audit of clinical The decision making circumstances/environment record process leading to IMP changes. Results from individual development and clinicians peer review Proposed timescales of IMP delivery. Standard 5: Implementing and Individual Management Plan (IMP) STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 5a. The Individual Management Planned and coordinated 5a.1. The clinical record and IMP Data relating to numbers Plan is implemented over a series intervention leads to better includes the detail, justifications of proportions of people of appointments with the outcomes. Such an approach and effectiveness of interventions being provided with opportunity for revision of needs, requires recording of interventions implemented. This included vestibular rehabilitation actions and outcomes at each and their effectiveness to guide referrals to other agencies. and those who are not. stage. The series of appointment ongoing development of the IMP. Service procedures is timely and may be referring to clinical record keeping. In order for agreed interventions Case study audit. to be effective, referral to another Patient feedback agency/service should be prompt 5a.2. Where referral to another Audit of time from patient so as to be based upon up to date agency/service is indicated, appointment to referral appraisal of need. referral is made from audiology being sent. within 7 days of the appointment in at least 95% of cases. 5b. Where provision of vestibular 5b.1. Audiologists Prior to should rehabilitation be confident Copies of local evidence rehabilitation services are that patient’s the client abilities is physically are assessed and based criteria and policies required the service ensures: and emotionally recorded. able to perform the Audit against these rehabilitation exercises criteria/policies. appropriately. Examples of journal each client receives an entries within patient individually tailored management system.
The IMP is flexible so that different goals can be set if the patient’s circumstances/environment changes. 4a.5. The clinical record includes details of: The decision making process leading to IMP development and Proposed timescales of IMP delivery. Service procedures referring to clinical record keeping. Case study audit of clinical record Results from individual clinicians peer review Standard 5: Implementing and Individual Management Plan (IMP) STANDARD STATEMENT RATIONALE CRITERIA EVIDENCE (EXAMPLES) 5a. The Individual Management Plan is implemented over a series of appointments with the opportunity for revision of needs, actions and outcomes at each stage. The series of appointment is timely and may be Planned and coordinated intervention leads to better outcomes. Such an approach requires recording of interventions and their effectiveness to guide ongoing development of the IMP. In order for agreed interventions to be effective, referral to another agency/service should be prompt so as to be based upon up to date appraisal of need. 5a.1. The clinical record and IMP includes the detail, justifications and effectiveness of interventions implemented. This included referrals to other agencies. Data relating to numbers of proportions of people being provided with vestibular rehabilitation and those who are not. Service procedures referring to clinical record keeping. Case study audit. Patient feedback 5a.2. Where referral to another agency/service is indicated, referral is made from audiology within 7 days of the appointment in at least 95% of cases. Audit of time from patient appointment to referral being sent. 5b. Where provision of vestibular rehabilitation services are required the service ensures: each client receives an individually tailored Audiologists should be confident that the client is physically and emotionally able to perform the rehabilitation exercises appropriately. 5b.1. Prior to rehabilitation patient’s abilities are assessed and recorded. Copies of local evidence based criteria and policies Audit against these criteria/policies. Examples of journal entries within patient management system.
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