Tool for Audit ofCare Plansin Day Care Services for Older Persons

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 Day Care Services for Older Persons

Methodology:

Inclusion Criteria: All persons utilising HSEDay Care 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 activity 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)

Method:This is a retrospective Day Care Plan audit

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

Tool for Audit ofCare Plans in Day Care Services for Older Persons

Residential Unit Name: ______

Section A: General Care Plan Content

Audit Number
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6
A1 / The client has a care plan
A2 / The care plan has been developed with the client and/or significant other
A3 / The clients name is on every page of the record
A4 / The individual’s care plan contains current: Day Care Admission
A5 / Missing Person Identification Profile
A6 / Initial Admission Assessment
A7 / Communication assessment
A8 / Breathing and Circulation Assessment
A9 / Nutrition and Hydration Assessment
A10 / Mobility and Safety
A11 / Personal Care / Controlling Body Temperature/ Self-Image info
A12 / Waterlow Score / Pressure Ulcer Prevention and Wounds Assessment
A13 / Spiritual Needs Assessment
A14 / Hobbies interests and occupational history is recorded
A15 / The Care Plan contains the following: MNA Nutritional Weight Assessment
A16 / BMI and Weight are recorded
A17 / Falls Risk Assessment
A18 / Manual Handling Assessment (appropriate tool to be sourced)
A19 / Dependency Scale (Barthel/CAPE)
A20 / Other assessments as required
A21 / The Temperature, Pulse and Respiration Chart is completed 3 monthly and within date
A22 / The Monthly weight chart is being completed 3 monthly
A23 / A care plan is written when a need/ risk is indicated by the nursing assessment and the assessments tools
A24 / The Care Plan contains current information on the following: Problem Identification
A25 / Goal specification
A26 / Specific Interventions
A27 / Evaluations of Care/Communication page
A28 / Daily Activities chart is completed
A29 / Daily Activities charts use the appropriate coding
A30 / The communication page reports meaningful information
A31 / Referrals made to multidisciplinary team are supported by the purpose for the resident review and the reasons for the referral as required
A32 / Multidisciplinary assessments are completed as required and are current
A33 / All resident assessments are dated
A34 / All resident assessments are signed
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
34 – Total 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 annually
B14 / The Care Plan reassessment is documented annually
B15 / Unexplained absence is recorded
Total Scores for Yes
Total Scores for No
Total Scores for N/A
Total = 15% Total =Total Scores for Yes X 100
15 – Total 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 Day Care Services for Older Persons, QPS DML, June 2014 Page1 of 5