Clinical Audits are done with the sole purpose of improving the quality of health care given to the patients and thus provides a framework of what and how things should be done.
In a clinical audit, the performance is reviewed along with the auditing of the clinical documentation to see things are as per the standard set by the regulatory bodies of the country.
The rules of the clinical audit are controlled by the standards of the clinical governance.
The process of the audit demands systemization for improved care giving and thus making the total experience of the person involved more positive.
Clinical audit also involves the systematization of the various procedures used for diagnosis and the subsequent treatment, also examining how the associated resources are used in the treatment while investigating how the treatment and care has improved the life of the patient or otherwise and since all the documents are kept in the clinical documentation, this becomes a vital source for all relevant information.
Here are different types of clinical audit like the adverse occurrence screening, peer reviews; case note analysis, critical incident audits and the criteria based audits.
It may also include the core standard patient record audit, core standard CPD/LLL audit, patient feedback audit and the service standards audit.
Whatever be the type of audit, the clinical documentation is of vital importance in all of these especially in the clinical audit cycle.
Clinical audits are definitely an integral part of clinical governance as maintain the standards are very important and overall it should vouch to provide quality health care to the people.
At the same time, the audits are made to ensure that the practices in the clinical documentation fields re up to the mark and transparent policies are practiced.
It thus helps to promote service deliveries and effectiveness.
The top and the important audit tool includes the setting of the core and the service standards which moves on into the second which is comparing the practices with the standards and then implanting any changes that is required.
These audit tools are designed to measure the standards and the performance in various ways depending on the clinical documentation that will be evaluated to see if the standards and the criteria have met.
The top five audit tools will help you analyze the core, the standard services provided, and the tools may be used in different stages.
The five top tools are the Core Standards Patients Record Audit which provides the opportunities for both education and training, the second is Core standards continuing professional development or for lifelong learning CPD or the LLL audit, the Patient feedback audit which also includes a feedback questionnaire, service clinical audits which assesses the conformance of the organization against service and the given criteria.
Clinical documentation plays an important role in all of these.
It is also important that the audit tools be reviewed at least every 6 months to monitor the progress.