Cca Sample Client Record Audit Page 2
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3Canadian Centre for Accreditation | Community Organizational Health
Centre canadien de l’agrément | Santé des organismes communautaires
PART 2: QUALITY OF SERVICE AUDIT – EARLY YEARS
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1.
Is the presenting problem, chief complaint or reason for visit recorded for each
visit?
2.
Is there an adequate description of the presenting symptoms or issue?
3.
Is there a diagnosis or provisional diagnosis? (Must be assessed considering the
scope of practice of each professional involved in the client’s care)
4.
Is the treatment plan clearly recorded?
5.
When summary recording forms are used, do they conform with the expected
standards for the profession?
6.
Is the follow up of clients suffering from chronic conditions appropriate?
7.
Is there documented evidence that health maintenance and health promotion
strategies are discussed on a periodic basis or as needed?
8.
Is the documented investigation and subsequent plan appropriate to the
complaint/condition/problem?
9.
If counseling or psychotherapeutic sessions have been provided, does the
record indicate the content of discussions and the client’s response?
10.
Does the record indicate awareness of other resources in the community, which
might benefit the client?
11.
Do consultations with/referrals to other providers, including specialists, appear
to be appropriate?
12.
Does the record indicate that emergencies or crisis situations have been dealt
with promptly and effectively?
13.
Is there evidence of continuity of care in the absence of the primary provider?
14.
In your professional opinion, does this record present a clear and accurate
picture of the care provided to this client by the CHC staff?
15.
Is there evidence in the health record that staff from different professions in the
CHC have consulted each other about the care of the client, if appropriate?
16.
Does the record indicate an assessment of the impact of education, housing,
employment, income, social support, environmental risks, etc. on the health of
the client as appropriate?
17.
In your professional opinion, is this record an effective communication tool
between interdisciplinary health care providers?
18.
Where appropriate, has the child’s developmental progress been identified?
19.
Does the client record indicate shared decision-making between providers from
different professional backgrounds / partnering agencies?
20
Where appropriate, has a summary note been completed upon completion of
program?
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