RBWH Acute Care Team Clinical Documentation Audit - Jan - March 2023

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Closes 31 Mar 2023

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MNMH Acute Care Team Clinical Documentation Audit

1. Please enter the consumers CIMHA ID details:
2. Is the consumers demographic information complete in CIMHA, with the inclusion of a telephone number, address and NDIS status (without CIMHA validation errors)?
(Required)
3. If demographic information has not been recorded, please specify what information has been omitted:
4. Are the contact details for External Contacts recorded in CIMHA, including a next of kin and General Practitioner (cross-reference The Viewer for currency)?
(Required)
5. Is there a Triage Screen completed in CIMHA? (record as N/A if another Assessment tool e.g. Comprehensive Assessment, Focussed Assessment, Focused Assessment plus Substance Use has been completed)
(Required)
6. Please enter the initials of the clinician who completed the Triage Screen:
7. Does the Triage Screen appropriately document the following:
(Required)
8. Where risk was identified on the Triage Screen, has the Risk Screening Tool also been completed?
(Required)
9. Has an assessment tool (e.g. Comprehensive Assessment, Focussed Assessment, Focused Assessment plus Substance Use) been completed? (record as N/A if the Tirage Screen has been completed)
(Required)
10. Please enter the initials of the clinician who completed the assessment tool:
11. Does the assessment tool appropriately document the following:
(Required)
12. Is there evidence of a safety plan being developed with the consumer?
(Required)
13. Is there evidence that collateral information was sought, or attempted to be sought as part of the assessment? e.g. family, carer, General Practitioner, non-government organisation or other relevant service provider/s.
(Required)
14. Is there evidence of consent to share information documented on the MNMH Consent to Collect and Disclose Information form, or within the progress notes?
(Required)
15. Are the Alerts recorded in CIMHA consistent with the most recent Risk Assessment and consumer history?
(Required)
16. Are any allergies identified via the Triage Screen or assessment tool recorded as an Alert in CIMHA?
(Required)
17. Are relevant Alerts recorded in CIMHA, also recorded in HBCIS/ieMR?
(Required)
18. Where a consumer has been identified as having access to a firearm and has been identified as an unsuitable person to possess a firearm for either of the following reasons A. because of the person’s mental or physical condition; or B. because the person may be a danger to himself, herself or someone else – is there evidence of notification to the Weapons Licencing Branch?
(Required)
19. Where a consumer has been identified as having care responsibilities for children under the age of 17, has a Child Protection Form been completed?
(Required)
20. Where child protection concerns have been identified in a consumer’s presentation, is there evidence of liaison with the Child Protection Liaison Officer and/or a child protection notification?
(Required)
21. Has the consumers smoking status been recorded in CIMHA?
(Required)
22. Where a consumer has been identified as using tobacco products, has the Smoking Cessation Clinical Pathway been completed?
(Required)
23. Has a Longitudinal Summary been commenced or updated with new clinical information?
(Required)
24. Where the consumer is receiving treatment under the Mental Health Act 2016, is there evidence that the consumer has been informed of their rights and avenues for dispute?
(Required)
25. If a Service Episode has been commenced in CIMHA, is there evidence of a confirmed diagnosis?
(Required)
26. If a Service Episode has been commenced in CIMHA, is there evidence of a confirmed secondary diagnosis?
(Required)
27. Is there evidence of a plan developed and documented for the consumer, following discharge from the service?
(Required)
28. Is there evidence of family, carer and other supports being engaged in the discharge plan for the consumer?
(Required)
29. Is there evidence that the consumer has been provided information on how to contact the service post discharge?
(Required)
30. Where indicated, were referrals made to other relevant service providers (e.g. Alcohol and Drug Service, The Way Back Support Service, Hospital 2 Home, Head to Health)?
(Required)
31. Is there evidence that discharge information (e.g. Discharge Summary) has been provided to relevant service providers?
(Required)
32. Where a consumer has presented via the Emergency Department, is there evidence that each contact with the consumer and a plan for ongoing management has been documented in both EDIS and CIMHA? (TPCH and RedCab only)
33. Where the consumer could not be assessed due to time restraints or their level of intoxication, is there is clear documentation in EDIS/CIMHA about why the assessment was not commenced?
(Required)
34. Any additional comments regarding the clinical documentation?