Practice Audit

Tips for Practice Audits

  • Down load the documents
  • Ask an accredited Gold star RN to oversee audit
  • This process can be done via zoom, facetime, messenger video call etc
  • Pre prepare your documents prior to the audit maybe send some via email first
  • Cost $150 – $100 will be paid to auditing nurse $50 to CANN for final assessment of documents and clinic certificate

 

CANN Audit of Practice

Name of RN

Assessor

Date of assessment

Clinic address

Purpose

The purpose of this document is to ensure safe practice and to provide minimum criteria to prove competence. This assessment is triannual and mandatory to maintain accreditation with CANN. This audit will be performed on all CANN accredited RNs after they have completed the paperwork and process for becoming accredited with CANN.

Audit failure will result in a Plan for improvement which will be agreed upon between RN and auditor. Following the completion of the Plan for improvement, the audit will be conducted again and another auditing cost will be incurred. When a repeat audit is required a different auditor will be assigned to assess the RN. If the RN fails to pass the repeat evaluation, their certification will be terminated. 

The examiner will spend approximately two hours observing the member, interviewing staff and examining records at their primary medical premises. The member will only be assessed for cosmetic injecting, not other scopes of nursing practice.  

Standing orders will be observed to ensure that RNs are meeting compliance with legal requirements.

The audit will include review of 15 client files, medical equipment, review of facilities and safety equipment and samples of advertising used in the past 12 months.

Instructions for audit:

  1. Select 15 client files at random from the previous 12 months
  2. Mark against the listed criteria 
  3. Complete the Plan of Improvement and give this to the Registered Nurse
  4. Registered Nurse to document Plan of Improvement
  5. Review of Actions and plans to be agreed upon at a later date

Instructions for marking:

Each file to have correct box marked

   – Documentation present and correct

N/M – Not met.  Present, but Inadequate documentation

N/P – Not present

N/A – Not applicable

Example:

Documentation123456789101112131415
Client Name             
Addressnp             

The above shows that File 1 has both client name and address correct. File 2 has the Client name correctly documented, but the address was not present.

Scores are gathered from non-highlighted boxes throughout the audit.

Some criteria audited is not applicable in some clinics. These are given a N/a option to mark. This will not negatively impact the outcomes for the nurse being audited.

It is likely that a successful candidate will have scores totalling higher than denominating mark.

CANN Audit of Practice

Client Details/Demographics

Documentation123456789101112131415
Client Name               
Address               
Phone Contact               
Gender               
Date of Birth               

/75

Medical Records

Documentation123456789101112131415
Allergies/sensitivities               
Medical History               
Medication List               
Specialist Letters if applicable               
Physical awareness alerts if applicable               
Mental health needs if applicable               
Lifestyle alerts if applicable               

                                                                              /45

Scores are gathered from non-highlighted boxes.

 

Treatment Records

Documentation123456789101112131415
Dated               
Treatment provider name (if applicable)               
legible               
Previous outcomes recorded               
Products used               
Batch number               
Product amounts used and location placed               
Technique used               
Follow-up/rebook               

    

                                                                                                   /105

Scores are gathered from non-highlighted boxes.

Professional Development Plan

 YesNo
Does the plan identify needs  
Does the plan set goals  
Is the plan able to be reviewed by a senior staff or mentor  
Does the plan outline steps to achieve goals  

/4

Attach copy of Professional Development Plan

Standing Orders

 YesNoN/a
Does the Standing Order meet the Ministry of Health Standing Orders Guidelines and legislative requirements    
Is the process for countersigning/auditing clearly defined and being adhered to?   
Are treatments being performed within the RN’s scope of practice and in accordance with their Standing Orders   
Are the Standing orders current   
If unapproved medications are administered (section 29), is a record being kept for each administration?    

/4

Clinic: Advertising

 YesNoN/a
Does print media satisfy NZSCM’s Advertising and Ethics Standards   
Does Social media content satisfy NZSCM’s Advertising and Ethics Standards   
Does radio and television media satisfy NZSCM’s Advertising and Ethics Standards   
Is there evidence of Taps approval   

/8

Please note that N/a = pass

Clinic: Adverse Events management

 YesNo
Are there clear instructions on how to document, log and submit AEs  
Are there protocols for AE management  
Is there a clear network of support  

/3

Clinic: Emergency Equipment

 YesNoN/a
Defibrillator (if required by SO doctor)   
Ambubag with mask (if required by SO doctor)   
Guedal Oropharyngeal airways (if required by SO doctor)    
Non-rebreathing mask with oxygen tubing (if required by SO doctor)   
Oxygen cylinder with regulator, cylinder key, tubing and Hudson mask (if required by SO doctor)   
Stethoscope   
sphygmomanometer   
IV cannula (if required by SO doctor)   
Gloves   
Resuscitation and anaphylaxis Guidelines   
Hyaluronidase 1500 iu x 3 vials   
Adrenaline/Epipen(if required by SO doctor)   

/105

PLEASE NOTE THAT N/A = PASS. SCORES ARE GATHERED FROM NON-HIGHLIGHTED BOXES.

Clinic: Health and Safety

DocumentationYesNo
Current Health and Safety manual  
Protocol on management of Waste and Hazardous Substances  
Protocol on clinical emergency and transfer  
Protocol on Resuscitation  
Fire Evacuation Scheme as outlined in FSA 1975 s.21 and clause 17 of the Fire and Safety Evacuation of Buildings Regs. 2006  
Environment is appropriately clean  
Infection control promoted, cleaning processes in place  
Ability to wash hands with soap and water or use hand gel  
Sharps disposal available  
Ability to maintain cold chain (if applicable)  
Medical records stored in a lockable area/ cabinet  

/11

Audit Totals

 Score
Client Details                  /75
Medical Forms                   /45
Treatment Records                /105
Health and Safety                  /11
Emergency Equipment                /105
Professional Development Plan                    /4
Adverse Events managementScore multiplied by 10             /30
Standing Orders    Score multiplied by 3           /12
Advertising                    /8
Total                /395

Pass                 Fail                   (Please circle)

Pass – 375/395 Over-all plus a score of 30 for Adverse Events Management 

Fail – a score of less than 375/395 or less than a score of 30 on the Adverse Events Management section

Audit failure or will result in a Plan for improvement which will be agreed upon between RN and auditor. Following the completion of the Plan for improvement, the audit will be conducted again and another auditing cost will be incurred. When a repeat audit is required a different auditor will be assigned to assess the RN. If the RN fails to pass the repeat evaluation, their certification will be terminated.

Printable Version:

CANN Audit of Practice – updated (1)