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:
- Select 15 client files at random from the previous 12 months
- Mark against the listed criteria
- Complete the Plan of Improvement and give this to the Registered Nurse
- Registered Nurse to document Plan of Improvement
- 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.
