High-quality clinical notes are important to ensure the accurate documentation of the consultation and provide pertinent information for other clinicians. Auditing notes helps identify areas of weakness, drives quality improvement and will result in improved patient outcomes.
Notes submitted to the College for audit counts as one audit for recertification purposes. Having notes assessed as part of clinic or workplace audit do NOT count as one of the triennial audits. In all cases, comments and feedback should be recorded, reviewed, and action taken to make the necessary adjustments. The feedback and actions taken (or to be taken) should be discussed at the annual conversation and may be claimed as CPD.
Submitting notes for audit
The following must submit notes to the College for audit:
- Registrars (within three months of joining the training programme, and subsequently every three years).
- Fellows who are not undergoing a regular review of clinical notes elsewhere (see below).
- Doctors completing a regular practice review.
- Doctors who have been recommended to submit notes by their Medical Director, clinic auditor, other person reviewing their notes (see below).
Details of how to submit notes for audit can be found here – link is currently to old CNA page, but most of the instructions remain the same.
Notes review process
The following may have their notes assessed by an appropriate person, though this review does not count as an audit for recertification purposes:
- Fellows working in an accredited Urgent Care Clinic. The Medical Director regularly performs internal audits of note quality.
- Fellows working in other locations who have received College dispensation for their notes to be marked by an appropriate person in the workplace. Provide link to form for dispensation.
If the Medical Director/appropriate person feels the doctor is consistently performing poorly in their internal notes audit, they may recommend the doctor submit an audit for College review – link/information required by DPD.