Education Chart Audit Instructions

Please see the attached two forms, Education Chart Audit Part 1 and Education Chart Audit Part 2. Part 1 provides documentation of education elements required for recognition or accreditation and serves as the “chart” audit form. It has been edited and is what you have been using previously to do your education chart audits. Part 2 captures the achievement of the patient’s behavior after attending Joslin’s Comprehensive Diabetes Education program. It is a new form and has been designed to better capture achievement of behavioral goals. This will allow Joslin Boston to provide aggregate data on what goals are being set and levels of achievement for these goals for the affiliates. The following instructions outline the auditing process for the clinic and affiliates to be conducted annually.

Part 1- Educational Process Documentation

Goal-Every educator will have complete, accurate documentation of the educational assessment, delivery of educational plan, reassessment of progress and a defined diabetes self management follow up support (DSMS) plan for patients enrolled in the diabetes program.

Process

  1. Conduct audit annually for Joslin Boston- 5 education records for each educator at the site. These audits can be conducted by the education coordinator or by peers, or educators themselves. If possible, educators should not audit their own records.
  2. Compile the data.
  3. Summarize the results, analyze and report to your advising committee.
  4. From the results, create and implement a quality improvement plan as needed.

Part 2- Patient Behavioral Goal Outcomes Development, Documentation, and Outcome Measurement

Goals

o  Every patient will identify at least one behavioral (measurable) goal at the conclusion of the educational experience.

o  Goal achievement is measured and documented at a reasonable interval post educational session (for example- 1-3 months, 6 months, etc). Audits for Joslin are conducted annually on the same 5 charts audited in Part 1.

Goal setting Process

1.  Collaboratively with the patient (family, and or significant other) identify behavior goals.

2.  In collaboration with a patient, prepare a written take home goal sheet handout, and make a copy of goals for the medical record.

3.  Establish a time table to check on patient’s achievement.

Auditing Process:

1.  Identify patient chart to audit, and review goal setting information.

2.  Using Part 2 audit tool, on the left hand side of the form, categorize each listed goal by topic areas (healthy eating, physical activity, etc.) provided. Circle appropriate goal category (1-7 Likert Scale) for each goal

3.  Rank each goal achievement by circling a Likert Scale number 1 (never) - 5(always) or 9.LTF (lost to follow up).

4.  Clearly write verbatim the patient goal in the column on the right hand side of the form.

5.  Summarize, analyze the results of this data, and discuss at your next advisory committee meeting for potential improvement planning.

Summary Requirements - Part 1 and 2

o  ADA and AADE education recognition requires an audit of all comprehensive education patients be completed and summarized during the selected data period every 3 years.

o  Joslin Boston requires that 5 audits per educator be collected and reviewed by Boston on a date determined each year and/ or at the annual site visit. Periodically, he actual forms used in the audit will need to be sent to Boston. The data from these forms will be aggregated and reported back to the affiliates. Please call # 1-617-226-5858 and speak to your site coordinator if you have questions.

o  This activity meets the requirements in Joslin’s policy AO-02 , and supports the ADA ERP and AADE DEAP activities.

Copyright © 2010 by Joslin Diabetes Center (www.joslin.org). All rights reserved.

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For permission for other use call (617-226-5815).