Tips for Practice Audits

  • ,Download 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
  • Once you have been audited and have uploaded your documents to CANN please notify [email protected] to have your audit checked and have your certificate for your clinic sent out to you. Your auditing nurse must notify [email protected] of their bank account for payment.
  • You must send a copy of your audit to your Oversite doctor for his records to produce for his NZSCM audit.
  • ____________________________________________________________________________________________________________________________________

New NZSCM Approved CANN Audit of Practice

Printable Version:

CANN-Audit-of-Practice-new edit bw

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 review of advertising and social media. 

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

               

Pregnancy/breast feeding checked

               

Previous treatment outcomes documented

               

Medical History

               

Medication List

               

History of previous dermal fillers documented if applicable

               

Specialist Letters if applicable

               

Physical awareness alerts if applicable

               

Mental health needs if applicable

               

Lifestyle alerts if applicable

               

                                                                              /90

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

               

Written consent has been performed within the past 12 months, and verbal consent has been obtained every time

               

Blindness, vascular occlusion/tissue necrosis, and delayed onset nodules in filler consent is in language that is easily understood by client.

               

Previous outcomes recorded

               

Products used

               

Batch number

               

Product amounts used and location placed

               

Technique used

               

Follow-up/rebook

               

    

                                                                                                   /120

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

RN articulates how to contact their SO doctor

   

RN can articulate the process of obtaining support when their SO is unavailable or on leave

   

RN can articulate how their annual competency review is performed

   

Does the Standing Order meet the Ministry of Health Standing Orders Guidelines and legislative requirements? Please see below

   

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? 

   

Standing orders must contain the following:

  • Date of issue
  • Date of expiration/validity
  • Name of issuing doctor and RN
  • Name of drugs for which the RN may dispense from the SO
  • Parameters of treatment, including dosages, scope and client suitability to treat /7

Clinic: Advertising

ALL advertising and social media should be reviewed. This includes the entire website and all social media posts currently visible on line, both clinic, personal and social media accounts that display treatment results. Both must be checked.  Old social media posts that are non-compliant must be edited to be compliant, or be removed, to pass. Billboards and signage should also be checked and must comply with NZ advertising regulations. The audit is the opportunity to ensure all currently visible advertising complies with regulations.    

 

Yes

No

N/a

Does print media satisfy relevant legislation such as the Medicines Act, the Fair Trading Act and industry standards?

   

Does Social media content satisfy NZ advertising regulations 

   

Does radio and television media satisfy NZ advertising regulations 

   

/3

Please note that N/a = pass

Clinic: Adverse Events management

 

Yes

No

Are there clear instructions on how to document, log and submit AEs

  

Is there a protocol for the treatment of vascular events?

  

Is there a protocol for the management of blindness and dermal filler treatment?

  

Are there protocols for AE management for other delivered treatments?

  

Is there a clear network of support

  

/5

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 1 vial and/or Epipen available on-site

   

/6

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 

                  /90

Treatment Records

                /120

Health and Safety

                  /11

Emergency Equipment

      Score multiplied by 10          /60

Professional Development Plan

                    /4

Adverse Events management

Score  multiplied by 10             /50

Standing Orders

    Score multiplied by 10           /70

Advertising

      Score multiplied by 10             /30

Total

                /510

Pass                 Fail                   (Please circle)

Pass – 475 or higher Over-all plus a score of 40 for Adverse Events Management 

Fail – a score of less than 475 or less than a score of 40 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-new edit bw

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.