Tool for Audit ofCare Plansin Residential Services for Older Persons

Residential Unit / Community House Name: ______

Objective of Audit tool:

This audit tool is to be used to retrospectively audit the processes used in Care Planning in HSE Residential Units for Older Persons

Methodology:

Inclusion Criteria: All persons residing withinHSE Residential Units for Older Persons in (insert Location)

Frequency of Audit*: e.g. Every three months: Random selection of charts. The number of charts to be audited to be determined by each site based on bed numbers and assurance requirements – but no less than five charts to be audited every three months.

(*Note: this is just a suggestion – frequency to be determined by each individual service)

Feedback: Completed Audit Tool to be kept in the Audit File on the Unit.

Final page of the Audit Tool to be forwarded to the Director of Nursing for onward reporting

Audit Details:

Unit / House / Date of Audit
Auditor(s) Name(s) / Auditor(s) Title (s)
Resident Identifier (name/ medical card number) / 1. / 2. / 3.
4. / 5. / 6.

Methodology: RecordY for Yes, if the item is found in the resident’s care record.

Record N for No, the item is not present or N/Afor Not applicable

Audit Tool ofCare Plansin Residential Care Services

Residential Unit Name: ______

Section A: General Care Plan Content

Audit Number
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6
A1 / The individual has a care plan
A2 / The care plan has been developed with the resident and/or significant other
A3 / The residents name is on every page of the record
A4 / The residents medical record number (or DOB if no MRN number) is on every page of the record
A5 / The individual’s care plan contains current:
Biographical information
A6 / Missing Person Identification Profile
A7 / Initial Admission Assessment
A8 / Communication assessment
A9 / Breathing and Circulation Assessment
A10 / Nutrition and Hydration Assessment
A11 / Mobility and Safety
A12 / Personal Care / Controlling Body Temperature/ Self-Image info
A13 / Skin Condition / Pressure Ulcer Prevention and Wounds Assessment
A14 / Sleep and Rest/ Spiritual Needs Assessment
A15 / Personal History Profile (A key to me)
A16 / Personal Calendar of Important Dates
A17 / Meaningful ActivitiesAssessment PAL
A18 / The Care Plan contains the following:
Water-low pressure ulcer risk assessment chart
A19 / MNA Nutritional Weight Assessment
A20 / BMI and Weight are recorded
A21 / Falls Risk Assessment
A22 / Manual Handling Assessment
A23 / Dependency Scale (Barthel/CAPE)
A24 / Oral Cavity assessment
A25 / Continence assessment
A26 / Other assessments as required
A27 / The Temperature, Pulse and Respiration Chart is completed and up to date
A28 / The Monthly weight chart is being completed and is current
A29 / The Fluid Balance Chart is being completed and is current
A30 / A care plan is written whena need/ risk is indicated by the nursing assessment and the assessments tools
A31 / The Care Plan contains current information on the following:
Problem Identification
A32 / Goal specification
A33 / Specific Interventions
A34 / Evaluations of Care
A35 / Daily flow charts are completed morning and night
A36 / Daily flow charts use the appropriate coding
A37 / Narrative notes are completed appropriately and adequately
A38 / Referrals made to multidisciplinary team are supported by the purpose for the resident review and the reasons for the referral
A39 / Multidisciplinary assessments are completed as required and are current
A40 / All resident assessments are dated
A41 / All resident assessments are signed
Resident with an infection
A42 / An infection care plan is initiated once the infection is noted
A43 / Interventions to address the infection are being implemented
Person Centred Care
A43 / The care plan informs how to care for the resident
A45 / The problems are specific to the resident
A46 / The health needs are addressed
A47 / The personal needs are addressed
A48 / The social care needs are addressed
Total Scores for Yes
Total Scores for No
Total Scores for N/A
Total = 48% Total =Total Scores for Yes X 100
48- N/A

Comment:______

Section B: Correct completion of the care plan

Audit Number
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6
B1 / Writing is legible
B2 / Black ink is used at all times
B3 / Entries are signed, dated and timed
B4 / The 24 hour clock is used
B5 / Signatures are legible
B6 / A Signature sheet is available at the front of the care plan and is <6 months old
B7 / Appropriate abbreviations are used (in line with HSE guidance)
B8 / Any errors are bracketed, have a single line drawn through it and are signed and dated
B9 / Entries have not been altered
B10 / Language is clear and not subject to misinterpretation
B11 / Accepted grading systems are used
B12 / Any entries by students are countersigned by the relevant qualified professional
B13 / A Care Plan reassessment takes place every three months
B14 / The Care Plan reassessment is documented in three monthly review form
Total Scores for Yes
Total Scores for No
Total Scores for N/A
Total = 14% Total =Total Scores for Yes X 100
14 - N/A

Comment:______

Section C: Audit Outcomes and Recommendations

Unit:______Ward:______Date:______

Audit Results / 1 / 2 / 3 / 4 / 5 / 6
% Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance
Section A
Section B
Audit Outcomes / 1 / 2 / 3 / 4 / 5 / 6
Yes / No / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
Care Plan processes were appropriately applied at all times
There were deviations from the correct Care Plan processes
Recommendations for improvement are required
Recommendations arising from the audit: / Date for completion / Responsibility
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5
Resident 6

Signature of Auditor: ______Date:______

CNM Signature:______Date:______

Director of Nursing Signature: ______Date: ______

Tool for Audit of Care Plans in Residential Services for Older Persons, QPS DML, June 2014 Page 1 of 5