Clinical Documentation Audit Tools

The sole purpose of clinical documentation is monitoring the quality and standard of health care provided. Clinical governance mirrors the responsibility and accountability of health care management and health care givers towards maintaining quality and high standards in treatment. As a main feature of clinical governance, clinical audits are conducted to review performances and maintain clarity contributing to the improvement of the documentation process.

Out of Hours Toolkit

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As the name suggests, the out of hours clinical documentation improvement toolkit has been designed by the physicians of the Royal College of General Practitioners to audit out of hours services. It uses same sets of criteria for call receivers, physicians, patient handling and treatment process. This criterion measures the outcome of the work done by each personnel i.e. the degree to which the needs of the patient were met with a score of 0 to 2. 0 indicates the needs weren't met at all, 1 indicates that needs were met partially and 2 indicates that the needs were fully looked into. The out of hours toolkit is a very handy audit tool, which thoroughly evaluates out of hours services.

IMRCI - Back Pain Audit Toolkit

While creating this toolkit for back pain, four main areas of guidelines were paid attention to. They are active lifestyle, exercise, bed rest and manipulation. A systematic review of these key areas is followed by
• Assessment of the first diagnosis
• Assessment of psychosocial factors
• Medication
• Investigations and treatments followed

However this audit tool kit has several flaws. Firstly, it focuses on the first visit and not on the entire process of treatment. There is no place for reviewing the treatment details, which is so essential. Lastly, no separate standards have been set for back pain audit, i.e., this toolkit does not have standards to compare each criterion.

Sigmund clinical documentation software

Sigmund's software for clinical documentation improvement is a fully computerized system for maintaining documentation right from the admission to the discharge of a patient. It has tools for monitoring the quality, accuracy and timeliness of documentation. The software's task assignment, automatic document assessment and e-signature features further streamline the documentation process thus increasing the output while cutting down on waiting time for patients. The software's special documentation tools keep track of drug usage history, manage tasks and schedules, create patient alerts and conduct and review the charting process while keeping tab of the documentation requirements.

Concerto Clinical Documentation

Orion health's clinical documentation improvement software seeks improvement of the quality and accuracy of EHR (Electronic Health Record) system, bypassing the age-old paper works. The software provides easy to use customizable templates for accurate recording of patient information. A very efficient feature, Concerto's in built form designer tool enables health-care professionals to design document templates as per need without seeking professional help. The software also enables physicians and health-care workers to tab data, keep track of the documentation process, create reports and analyze patient progress and outcomes.

Audit tools help in the entire clinical documentation improvement process by streamlining work flow and ensuring accuracy in record keeping.

Clinical documentation audit maintains a high level of clarity in the entire treatment process with the greatest beneficiary being the patient. The audit's aim is continuous improvement of the care provided and conformance to the rules and regulations of the regulatory body.

Clinical Documentation Audit Tools

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