Is your charting affecting your hospital’s certification?
Audits by the Ministry of Health have highlighted concerns regarding standards for charting anaesthetic drugs. New Zealand Society Anaesthetist (NZSA) Executive member Kaye Ottaway outlines the areas of non-compliance, the remedial actions taken, and urges compliance with Ministry of Health certification requirements.
The standard of drug charting has been one of the focuses of the Ministry of Health’s Hospital Accreditation audits this year.
The NZSA was contacted by a Dunedin anaesthetist in April enquiring about the standard of charting for anaesthetic charts.
There had been much criticism of the charting of medications, and:
- Failure to use the full name of the drug administered
- Failure to write the units either in full or at all
- Failure to chart the time of administration
- Charting of antibiotic administration especially the time of administration.
Following this audit, further audits in Auckland private facilities highlighted other areas of concern to the Ministry of Health. These included:
- Standing orders – the format of and the failure to countersign these by the prescriber
- Anaesthetic charts once again
- Postoperative charting – failure to write full drug names, units, times of administration, indications and 24-hour drug limits.
Random audits of hand written records at two different hospitals, found that no records fully complied with what the auditors required.
The Australian and New Zealand College of Anaesthetists (ANZCA) professional document PS06 The Anaesthetic Record. Recommendations on the Recording of an Episode of Anaesthetic Care is a useful resource, as well as the documents recommended in the CPD workbook relating to auditing of anaesthetic records from the RCA.
Electronically generated anaesthetic records do fulfil the auditors’ requirements but standing orders and postoperative medication charting are areas of concern.
Whilst there are no standards for anaesthetic charts per se they are considered an administration record.
If the National Medical Chart (NMC) is used, as in the Southern Cross Hospital group, the format is such that, if filled in as per the Medication Charting Standard, charting would comply with the Ministry of Health auditors. See: Medication Safety – national medication chart toolkit.
This may seem to be a minor issue but one facility was in danger of losing its accreditation due to the number of failures to comply with these standards. This required the following remedial actions:
- A complete update of the format of standing orders and actions to make sure they were signed.
- Revising the anaesthetic chart to incorporate more pre-printed drug names written in full along with units written in full beside the names
- Revising the section for antibiotic administration
- Revising the section for timing of administration of local blocks along with the drugs used
- Introduction of the Day and Long Stay NMC with education regarding the charting of drugs and access to the Standards.
Allergies and Alerts also need to be completed as do the VTE risks and prophylaxis, In addition, prescribers need to remember to fill in their name, signature and Medical Council registration number. Auditors, in the past, have allowed lists of regular prescribers to be available in private hospitals but this situation may change in the future.
ACC also requires that its Lead Providers provide ASA data for their audits. The ASA needs to be completed by anaesthetists either on the electronic record or hand written record.
Contact SAFERsleep to see how we can assist in this process and allow you to assist the hospitals to comply with the Ministry of Health certification requirements.