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Putting prevention into practice (Green Book)

Case note audit

Case note audit is a ‘systematic and objective method of analysing the quality of care provided by clinicians. They are a way of identifying areas for improvement and assessing how well your practice is achieving its goals.171 Case note audit requires:

  • a systematic evaluation of an aspect of care
  • a comparison of the results against some standard, either implicit or explicit
  • an assessment plan to improve the quality of care provided.

Several principles are worth keeping in mind when you conduct an audit:

  • Purpose: focus on education and relevant to patient care
  • Control: should be directed by clinicians and/or peers
  • Standards: ideally this should be explicit and set by appropriate clinicians or others participating
  • Method: should be nonthreatening, repeatable (reliable), simple, and cause as little disruption as possible
  • Records: adequate clinical records and retrieval systems are essential. Computerised records with electronic recording of key information greatly facilitate this process.

With the development of the right audit tool, the process can be undertaken by administrative staff in the practice as necessary. An audit will allow the monitoring of interventions made or messages given and patient uptake of the interventions. In turn, this will allow increased focus on problem areas. Case note audit offers a number of advantages in assessing clinical performance including:

  • the ability to determine need, assist with problem solving and attainment of goals
  • assessment of information that reflects the doctors clinical activities and quality of care
  • acceptability as a marker of clinical performance consistent with the PDSA cycle

Problems associated with an audit include:

  • legibility of the records
  • difficulties in distinguishing between errors of both omission (not doing an activity) and commission (forgetting to record the activity in the case notes)172
  • variable impact on improving the quality of care173,174
  • many preventive activities that occur in the consultation are more likely to be underdocumented by the GP than more traditional clinical activities (hence audit frequently underestimates GP performance when compared with patient report)
  • relatively time consuming and expensive, especially if conducted by doctors
  • may not be representative of all the patients treated
  • variability in the consistency (reliability) of assessment especially when compared with other evaluation techniques (eg. patient survey,175 simulated patient visit and GP self report).

Use your practice team’s knowledge

The members of your team may be able to help you with the needs of your patients based on interactions with them at the practice. There may be trends noticed in health issues for some patients coming to the practice. Use team meetings to identify trends.