Audit Tool for Admission Processes

Audit Tool for Admission Processes in (Location/ Service)

Objective of Audit tool:

This audit tool is to be used to retrospectively audit the processes used for Admission in line with the Mental Health Commission Code of Practice (2009), The Quality Framework for Mental Health Services in Ireland (2007), Article 15 of the Mental Health Act (2001) - Regulations (2006) and the MHC Guidance Document on Individual Care Planning MHS (2012).

Methodology:

Inclusion Criteria: All residents admitted to an Approved Centre

Frequency of Audit: Random Selection of Patient charts –(number and frequency to be decided by the MDT team)

Method:This is a retrospective care plan audit

Feedback: Completed Audit Tool to be kept by the CNM/ Unit Manager (to be agreed).

A copy of theOutcomessection of this Audit Tool (Section F) to be forwarded to Clinical Director/ Director of Nursing (to be agreed) for onward reporting of audit outcomes.

Audit Details:

Audit Type / Quarter 1 audit Quarter 2 audit Quarter 3 audit Quarter 4 audit
6 monthly audit Post incident
Random audit Other, Please state: / Date of Audit
Auditor(s) Name(s) / 1.
2.
3. / Auditor(s) Title (s) / 1.
2.
3.
Details of Prescription audited
Date reference number / 1. / 2. / 3.
4. / 5. / 6.

Methodology: RecordY for Yes, if the criteria is met. Record N for No, if criteria is not met or N/Afor Not applicable

Audit ofAdmission Processes

Unit Name: ______

Section A: Pre-Admission Process.
Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6
Planned Referral from Primary Care to Community mental Health Services :
A1 / An assessment was carried out by Primary Care prior to referral to Community Mental Health Services
A2 / A referral letter was received from Primary Care Services
A3 / The referral letter included the individual’s consent
A4 / The referral letter provided at least the following information:

• Level of Urgency

A5 /

• Presenting complaint

A6 /

• Current Mental State

A7 /

• Past Psychiatric History

A8 /

• Medical History

A9 /

• Current Medications

A10 /

• Relevant Risk Factors

A11 /

• Social Circumstances

A12 /

• Alcohol and/ or Drug Problems

A13 /

• Other relevant information

A14 / The information received at referral was placed in to the clinical file
Planned Referral to an Approved Centre by Community Mental Health Services
A15 / A Pre-admission Assessment was carried out by a designated member or members of the community mental health team
A16 / The individual’s eligibility for admission to an approved centre was established prior to referral
A17 / A referral letter or a referral telephone call was sent/made by community mental health services to the approved centre prior to admission
A18 / If a referral telephone call was made, the details of the call were documented
A19 / All relevant referral information was received by the Approved Centre
Unplanned Urgent Referral to an Approved Centre
A20 / An assessment was carried out by the approved centre as soon as possible (time frame?)
A21 / The assessment includes a Risk Assessment
A22 / The details of the referral were recorded
A23 / The details of the assessment were recorded
Self Referral
A24 / An assessment was carried out by the approved centre as soon as possible (time frame?)
A25 / The details of the assessment were recorded
A26 / The assessment includes a Risk Assessment
A27 / There is evidence of efforts to make contact with the individuals GP / Primary Care Team /Community Mental Health Team
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
Total = 27(Total – N/A)

Comment:______

Section B: Admission

Is there evidence that: / 1 / 2 / 3 / 4 / 5 / 6
Decision to Admit
B1 / Admission only occurred when the individual’s primary complaint was one of mental illness or mental disorder
B2 / Due regard was given to the interests of others who may be at risk of serious harm if the person is not admitted
B3 / The decision to admit was made by a registered medical practitioner or a consultant psychiatrist as appropriate
B4 / The decision to admit was made in conjunction with the MDT
B5 / With the consent of the individual, the decision to admit was made in consultation with the individual’s family / carer or chosen advocate
B6 / Alternative treatment options were explored before the decision to admit the individual
B7 / The individual was admitted to the unit most appropriate to his/ her needs
B8 / The individual was informed of the reasons to admit him/ her
Assessment following Admission
B9 / An initial assessment was carried out on admission
B10 / A more comprehensive MDT assessment was carried out as soon as possible after admission (Time Frames)
B11 / The Assessment included:

• Current Mental Health State

B12 /

• Risk Assessment

B13 /

• The Presenting Problem

B14 /

• Past Psychiatric History

B15 /

• Full Physical Examination

B16 /

• Medical History

B17 /

• Medication History and Current Medication

B18 /

• Family History

B19 /

• Social and Housing Circumstances

B20 /

• Information Needs

B21 /

• Any other relevant information

B22 / The Risk Assessment included the following 3 domains:

• Suicide Risk

B23 /

• Absconding Risk

B24 /

• Violence Risk

B25 / The individual was informed of his/ her rights upon admission
B26 / The individual understood his/her rights and this understanding was recorded in the clinical file
B27 / The individual was orientated to the staff and the unit to which he/she is being admitted
B28 / The individual was supplied with a resident information booklet
B29 / The individual was provided with information relating to

• Details of the individual’s MDT

B30 /

• Housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements

B31 /

• Verbal and written information on the individual’s diagnosis

B32 /

• Details of the relevant advocacy and voluntary agencies

B33 /

• Information on indications for use of all medications to be administered to the individual, including any possible side-effects

B34 /

• Information in relation to his/ her initial care and treatment plan

B35 /

• The information provided was in written and oral form and adapted to meet the needs of the individual

B36 / Where necessary and with the consent of the individual, information was conveyed to a personal representative
B37 / A Key Worker was assigned to the resident as soon as possible post admission
B38 / There is evidence that the Key Worker links with other members of the MDT and ensures that lison with relevant outside agencies takes place
B39 / Upon admission, a record was made of the resident’s personal property and possessions
B40 / The resident retained control of his/ her personal property and possessions except under the circumstances where this posed a danger to the resident or others as indicated by the individual care plan
B41 / If the resident did not have an adequate supply of their own clothing, the resident was provided with an adequate supply of appropriate individalised clothing with due regard to dignity and bodily integrity at all times
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
Total = 41(Total – N/A)

Comment:______

Section C: Admission Processes - Audit Outcomes

Unit Name: ______Date: ______

Audit Results / 1 / 2 / 3 / 4 / 5 / 6
% Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance
Section A
Section B
Audit Outcomes / 1 / 2 / 3 / 4 / 5 / 6
Yes / No / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
Care Plan processes were appropriately applied at all times
There were deviations from the correct Care Plan processes
Recommendations for improvement are required
Recommendations arising from the audit: / Date for completion / Responsibility
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5
Resident 6

Auditor Signature: ______Date:______

CNM Signature:______Date:______

Director of Nursing Signature: ______Date: ______

Audit Tool for Admission Processes, QPS DML, July 2014 Page 1 of 6