Clinical Notes Audit (CNA)

A notekeeping audit is a compulsory part of urgent care accreditation and reaccreditation. To complete this, send clinical notes to RNZCUC for review (instructions below).

 

Requirement

Registrars must complete a CNA in the first three months of joining the training programme.  A pass is required prior to attempting UCPEX, and every three years thereafter.

Fellows complete a notekeeping audit once every three years, though the audit reviewer can stipulate another timeframe.  Typically this happens if the notes are outstanding (in which case the reviewer may grant dispensation to ‘skip’ one cycle), or if they have only just passed (in which case the reviewer may require the CNA to be completed within one year).

When a doctor fails a CNA, the repeat CNA is required within three months, or as stipulated by the reviewer.

 

Introduction

Good notekeeping is particularly important in urgent care, and often done poorly. It is usual for urgent care clinical notes to be passed on to another doctor – be it another clinic doctor, a hospital doctor, or the usual GP. For this reason the quality of the clinical notes is particularly important in urgent care, and RNZCUC insists that its notekeeping standards be met as a condition of Fellowship. Good notes that are well presented in conventional format are easy for other doctors to understand. The underlying clinical practice may be sound despite poor notekeeping. Often though, poor notekeeping means poor clinical practice and a failure to think systematically – unsound clinical methods. If a patient complains about medical treatment, the notes will often decide the case.

Audit components

The notekeeping audit checks for the following basic elements:

  • History, including Presenting Complaint, Past Medical History, Current Medications and Allergies.
  • Examination findings, including Basic Observations
  • Diagnosis
  • Plan

In addition, the auditor will comment on any clinical concerns arising from the notes review.

 

Instructions to audited doctor

1) Print off TWENTY consecutive records of patients presenting for the first time for a particular episode.

Be sure to print off all clinically relevant notes, for the patient, including nurse triage notes, wherever they are stored in your facility’s record management system, including medications, allergies, and past medical history.

2) Anonymise by removing all identifying patient details, but leave clinically relevant fields visible, including ethnicity, age, and sex.

3) Please note any special or unusual features of the consultation, e.g. resuscitation case, difficult consultation, diagnosis uncertain, errors, or alternative approaches to the problem.

4) Please comment on your facility’s notekeeping system or systems:

  • What is the name of the notekeeping system? What is the software? If there is a paper component, including nursing notes, who designed them? Nurse, doctor or manager? Are they a standard design or customized? How could the notekeeping system or template be improved?
  • How well do you think your facility’s notekeeping template meets RNZCUC’s standard – i.e. is there a space and/or a prompt for each of the eight elements tested in this audit?
  • Any other comments on notekeeping or this audit?

Note: this is for reflection and discussion and is not measured in this audit.

5) Number each case and ensure it is clear which case each page of notes belongs to.  Ensure all documents are in the correct sequence. Please make sure you provide your name and medical council number.

Send to RNZCUC:

By post:

RNZCUC
110 Lunn Avenue
Remuera
Auckland
1072

Signed-for courier is recommended to avoid loss

By email:

Scan all documents.

Email to: admin@rnzcuc.org.nz

 

 

 

 

Common problems

The commonest problems are failures to record a patient’s past medical history and current medications.

This is especially common in apparently-well patients with an incidental presenting complaint, and in children.

However, patients may claim to be perfectly well, but on enquiry, are taking medication, for example, for asthma and peptic ulcer disease.

In the case of infants, an additional comment on the delivery and pregnancy is expected as part of the Past Medical History.

Failure to record Allergies is another common audit finding.

Sometimes very broad or vague or unconventional diagnoses are used, e.g. ‘visual problem, not related to injury’ or ‘Allergy’. Sometimes a symptom is recorded as a diagnosis, e.g. ‘sore throat’. This is seldom acceptable. Occasionally, a diagnosis is not recorded at all.

In many cases the audited doctor appears to have a haphazard approach to notekeeping, with information found in different places in different cases, and often not recorded. In some cases, it seems that if the nurse does not record data, such as PMHx, usual meds and allergies, it is not recorded at all.

Such notes are very hard to follow and call the doctor’s clinical methods into question.

Coping with poor facility notekeeping systems

A poor template and / or poor systems encourage poor notekeeping and poor practice. RNZCUC encourages urgent care physicians to pass on any concerns they have to RNZCUC and to their facility management.

When a facility’s notekeeping template is defective or missing, you may be able to create your own using the facility software – for example, a keyboard shortcut that produces the text ‘Past Medical History: Medications: Allergies:”

In many facilities, the nurse routinely records elements of history, past medical history, and basic observations. The responsibility for the medical notes remains with the doctor, and RNZCUC encourages doctors to both check the nurse’s history with the patient and acknowledge this in the notes, e.g., ‘per above nurse notes, verified.’

Sample clinical notes

An anonymised specimen clinical note follows. It is included as an example of a well-structured notekeeping system (and not for detailed scrutiny of the doctor’s management). It follows a conventional format as above. All information is in the expected place (e.g. all history findings under ‘history’) and in the conventional order. Even though it is an incidental injury in a seemingly well person, the doctor has enquired about PMHx, regular medications and allergies.

In this doctor’s audit, ALL notes followed this format. No information was omitted and it was evident that the doctor being audited had a consistent, logical and conventional notekeeping system.

Such notes are easy for another doctor to follow.

Instructions for auditor
Marking

Record a ‘1’ if the record is adequate and a ‘0’ if not.

If an item was not recorded and, you feel, not needed, record a ‘1’, as the record is therefore adequate.

If the doctor says the information is not provided because it is recorded elsewhere on the facility’s system, record a ‘0’ and suggest re-doing the audit with all the records. (The audited doctor is asked to supply ALL relevant records from all parts of the facility’s record storage system).

Assessment criteria
Item Pass / fail criteria Notes
History of presenting complaint? Must be present and adequate
Past medical history adequate? Must be present and adequate
Medications record adequate? Must be present and adequate Includes all current meds, longterm and short term. ‘0’ if only short term meds are mentioned.
Allergies or alerts recorded? Must be present and adequate
Baseline recordings adequate? Case appropriate e.g. T/P/BP in abdominal pain
Examination findings adequate? Case appropriate e.g. neurovascular status of limb in, suspected fracture; SLR in low back pain
Diagnosis recorded? Must be present and adequate Using conventional diagnostic terms, e.g. ‘contact dermatitis L arm’, and not ‘rash’
Plan? Must be present and adequate
Clinical concerns

Record a ‘0’ if you felt uneasy about the patient management, e.g. that important findings were not recorded, or that an important diagnosis may have been overlooked.

Also use the space to record any comments about the management for the doctor’s benefit or RNZCUC records, e.g.:

– a pattern of failure to record allergies, or neurovascular status in suspected limb fractures

– suggestion to use keyboard shortcuts to speed entry of mundane negative findings, when the doctor is writing them in full every time, or to provide a template.