Chart Audit and Feedback

Section 3: Assessment Activity

3 credits per hour

Rationale and Target Audience:

This tool is an opportunity for you to seek feedback on your chart audit activities from peers, colleagues or other health professionals. The feedback may help identify future learning and / or continuous improvement opportunities.

  Guideline Action Example
1. Identify an area of your practice to assess Choose an area of practice to assess your documentation. I would like to:
  • Audit and review my charts through thorough documentation of informed consent
2. Identify performance question(s) Identify specific documentation performance question(s) you have about your documentation (e.g. follow-up care required when handing over, consent discussion documented, clear drug tapering dosage requirements etc.). My specific question is:
  • Are all required processes for obtaining consent appropriately documented? (e.g. voluntary, patient informed about risks etc.)
3. Select one to three professional standards or criteria Select one to three criteria/standards to compare your audit against (e.g. medical regulatory authority guidelines, hospital/organizational documentation policy, legal requirements etc.). I will compare how I currently complete consent in my patient charts against:
  • CMPA’s good practice documentation guide
  • CMA’s code of Ethics and Professionalism
4. Assess your performance on a minimum of 10 patient charts Collect data on your performance based on a minimum of 10 patient charts. The data sources that I will use to learn more about my current performance:
  • Electronic Health record
5. Compare your current performance with the standards Review and analyze the data you collected about your performance in guideline #4 and compare it to the guidelines selected in guideline #3. This will help you identify gaps and learning opportunities. My current performance vs. existing standards:
  • In collaboration with colleagues, and self-chart review, identified need to better seek out, address, and then document patient questions while obtaining consent for certain procedures.
6. Discuss your findings with trusted peer(s) Share and discuss your findings with trusted colleagues, peers, or mentors to get input and feedback on the gaps/opportunities you identified and plan for next steps. I will collect, review and discuss feedback to facilitate this goal with:
  • Staff peers in my specialty
  • Actively engaged substitute decision makers (SDMs)
7. Identify the next steps for practice improvement Use the data and feedback you collected on your performance to identify the actions you will take to close the gap between your current performance (guideline #4) and your desired performance (guideline #5) (e.g. additional learning, modifications to a practice process etc.). The self-assessment of my practice identified that:
  • I need to allocate more time when addressing consent issues in cognitively impaired patients.
  • Verify substitute decision makers’ (SDMs) contact number info is on file and try to give more advance notice of consent discussion
8. Document this process and the outcomes in your MAINPORT ePortfolio Time spent on guidelines # 1 through #7 can be claimed under Section 3: Chart Audit and Feedback I spent X number of hours completing the chart audit process and 2 hours reviewing the feedback received from my colleague, and I created a plan of action for improvement. I will claim this activity in my MAINPORT account under Section 3: Chart Audit and Feedback

REFLECTION:

  1. What aspect(s) did the audit identify as done well?
  2. What aspect(s) were recommended for improvement?
  3. What specific actions (including additional CPD) are you are planning to complete to respond to the areas of practice that could be improved?
  4. What challenges, if any, do you anticipate in implementing these plans for improvement?
  5. What measures would enable you determine if the changes you are planning are successful?

bulb-light Use your reflections on these (or other similar questions) to record the outcomes on the feedback you received from a peer, colleague or health professional.

To claim MOC credit for this assessment activity, visit MAINPORT and complete the fields under Section 3: Chart Audit and Feedback, for 3 credits per hour.