Practice Audit

Tips for Practice Audits

  • Down load the documents (Printable version at the bottom of the page)
  • Ask an accredited Gold star RN to oversee audit
  • This process can be done in person preferably or via zoom, facetime, messenger video call etc
  • Pre prepare your documents prior to the audit maybe send some via email first (especially if you plan to be off site)
  • Cost $150 –  Paid via CANN – $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:

Documentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Client Name                          
Address np                          

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

Documentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Client Name                              
Address                              
Phone Contact                              
Gender                              
Date of Birth                              

/75

Medical Records

Documentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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

Documentation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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

  Yes No
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

  Yes No N/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

  Yes No N/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

  Yes No
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

  Yes No N/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

Documentation Yes No
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 management Score 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)

Uploading Instructions

Always click ‘My CANN’ to get into the private side of the website  – See your profile – at the side click: Accreditation – upload to the appropriate file (in this case clinic audit of practice)

You can also load your certificates here and the public should be able to see the certificates on your profile but the audits and everything else auditable are all hidden.

See below for tips that might help if you are struggling.

  • Only doc, docx and .pdf files are allowed to be uploaded. and in images format, .jpg, .jpeg and .png
  • In 1 field, only 1 document can be uploaded. You can not split cann scope of the audit into different parts (1 for each page) and expect to upload all of them into 1 field. You can only upload 1 file to 1 field. 
  • If your document scanner scans and outputs 1 page as 1 separate file, you can use any online free software like pdf merge and then merge those pages into 1 file and upload it. 
  • We have tried and tested and you can upload document upto file size of 40 mb and maybe more; the highest we tested was 40 MB
  • If you have a file uploaded, it will show as this https://prnt.sc/vs8m0n (download file). The plugin being used allows only this much wiggle room so can’t do a live preview of the file. 
  • The end – Please ask to hit the save button after uploading the document to make sure the changes are saved.