Beechdale Health Centre

Service Review Policy & Example Audit Template

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This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Beechdale Health Centre.

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Practice Statement

Beechdale Health Centre continuously strives to maintain the highest level of care to its patients by reviewing the services it offers, acting on any recognised shortfalls, and by being proactive in identifying areas of general improvement that could be made.

Policy

The Practice will do this by undertaking regular audits in the following provided service areas to ensure checks are made that:

  • Prove that correct consent is being sought;
  • Choice options have been discussed;
  • Disease registers maintained;
  • Medication compliance reviews are being performed;
  • Non-attendances of long-term condition reviews are recorded.

The Practice will also undertake regular surveys of patients to obtain their views on the services it provides.

The Practice will identify patients who should be on disease registers but are not already included by running regular reports within the clinical system which identify patients who are already prescribed drugs and / or who have had a diagnosis made indicating that they should be on a particular disease register.

Patients identified will be flagged, and their regular doctor informed who will then include them on the appropriate register.

Regular reports will also be run within the clinical system which identi

fy patients who have not had their medication reviewed within the last twelve months. Those identified will then be invited to make an appointment for a review to be carried out.

Patients who are on long-term conditions registers will be offered review appointments periodically.

The following time-periods will be adhered to:

  • Normal smear (patient aged between 25 and 49)
  • Normal smear (patient aged between 50 and 65

(Abnormal smears will vary depending on the result (see Cervical Smear Policy));

  • Diabetic review
  • COPD review
  • Asthma review
  • Heart disease

Patients that fall under any of the above reasons / conditions will be recalled after 3 consecutive months unless they decline the invitation in writing (this should then be noted in the patient’s record by a nurse or attend).

After 3 invitations, patients will be deemed to have declined by informed dissent and their record will be annotated accordingly. Their recall date will be reset for 12 months, hence for smears and chronic disease patients.

Where a patient repeatedly declines a review, this will be highlighted to their regular doctor who will determine if any further action is required.

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***Insert Name of Audit Being Undertaken***
***Insert Name of Author Conducting this Audit*** and ***Insert Audit Date***
Explain how you found your target group / Times between which records were sampled / Number of records that were sampled to determine the %age of patients where ***Insert Policy Name*** (e.g. Consent Policy) has been followed / What %age of records is the target for demonstrating compliance? / Actual %age results achieved / Action Plan / Responsibility / Timescales / Re-audit date / Responsibility
(e.g. running reports – include parameters used and state whether random or “all records”) / (e.g. Between 1st April and 30th June 2011) / (e.g. 100 records) / (e.g. 95%) / (e.g. 90%) / (e.g. identify missed patient groups and how these would be captured in the future / Dr Samuel Thompson / By the point of next audit – 27th August 2011) / (e.g. 27th August 2011 / Dr James Tolson)

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