Cca Sample Client Record Audit printable pdf download

Cca Sample Client Record Audit

Resource Library

Banque de ressources

SAMPLE: CLIENT RECORD AUDIT TOOL – EARLY YEARS TEAM

Keywords:

client records, audit, chart audit

Scope

The following is an example of a client record audit tool used to improve service. Administrative and quality of

service chart audits are combined in this two-part tool.

Procedures

MARVIN GARDENS SAMPLE ORGANIZATION

Chart Audit Tool – Early Years

Client/Chart ID #:

______________________________

Date of Review:

_______________________________

Name and Position of Auditor(s): _________________________

PART 1: ADMINISTRATIVE AUDIT

Yes

N/A

Is the record legible?

Is the date of each entry recorded?

Is each entry signed by the service provider?

Is a unique client identifier (e.g., client number) recorded on each page of the

record?

Are allergies or other alerts clearly documented?

Does the record contain basic client information including name, date of birth,

address, phone number and health card number?

Does the record contain all the forms required by the organization (e.g.,

registration form, Cumulative Patient Profile, Antenatal Record, Pediatric

Assessment Records, Early Years assessment forms, nutrition assessments)?

Are all required forms (see above) completed?

Are the file contents organized in a manner consistent with Marvin Gardens

guidelines?

10.

Does the record contain progress notes?

11.

Where appropriate, are the name and address of the referral source included?

12.

Where appropriate, is there a summary note to close the record?

13.

Is there documented evidence that the privacy policy has been discussed?

Comments:

Cca Sample Client Record Audit