Powys THB Occupational Therapy Service



Powys THB Occupational Therapy Service

Out patient and Community Patient audit tool.

Notes on filling in the form

OT standards are in BOLD, audit questions to see if the standards are met are preceded by Q eg Q1. when filling the questions in please try to use on yes no, if you have to use yes but you need to say what the “but” is, ie a legitimate reason that you did not score a yes.

The form

Location of base of therapist seeing patient_________________

MIP Number of Patient_________________________________

Name of auditor_______________________________________

R1 all referrals will be documented in an approved format, namely

- Powys Occupational Therapy referral form.

- Unified assessment/ enquiry form.

- Detailed letter.(IP,CP, and Paed)

Q1 Was the referral documented in an approved format?

Yes  No  No but ………………………

R2 telephone referrals will be recorded on the Powys Occupational Therapy referral form by the person receiving the referral. The name of the referrer and the person receiving the referral will be documented on the form.

(IP,CP, and Paed)

Q2 For telephone referrals was;

The name of the referrer recorded on the form?

Yes  No  No but ………………………

The name of the person receiving the referral recorded on the form?

Yes  No  No but ………………………

R3 the date the referral is received will be clearly recorded on the referral. (IP,CP, and Paed)

Q3 was the date the referral was received clearly recorded on the referral?

Yes  No  No but ………………………

R4 the referral will be screened to check sufficient information (all demographic details and reason for referral) prior to being accepted. The person doing the screening will initial and date that this has been done. (IP,CP, and Paed)

If the referral does not have sufficient information then for non-urgent referrals, it will be returned to the referrer explaining why it has been returned. For urgent referrals the referrer will be telephoned to obtain the necessary information.

Q4 has the person screening the referral;

Initialled that this has been done?

Yes  No  No but ………………………

Dated when this was done?

Yes  No  No but ………………………

R5 The referral will be allocated to an Occupational Therapy team member by a registered Occupational Therapist, and the person allocated to will be recorded on the referral form. (IP,CP, and Paed)

Q5 Has the team member to whom the referral has been allocated been recorded?

Yes  No  No but ………………………

Q6 Has the person doing the allocating been recorded?

Yes  No  No but ………………………

Q7 Is the person recorded as allocating the referral a state registered OT?

Yes  No  No but ………………………

R6 Referrals will be screened and prioritised as routine or urgent according to agreed criteria and this will be recorded on the reverse of the referral form. (IP,CP, and Paed)

Q8 has the priority been recorded on the referral form?

Yes  No  No but ………………………

R7 Routine referrals will be seen by the Occupational Therapy within the time scales listed below:

Inpatients 3 working days

Day hospital patients three attendances

Outpatients/ community patients four weeks (IP,CP, and Paed)

Q9 has the patient been seen by the OT service within the above time scales?

Yes  No  No but ………………………

R8 All referrals will be entered onto the patient management system, currently Myrddyn in Powys (MIP for short) within one working week. (IP,CP, and Paed)

Q10 has the referral been entered on MIP within one working week?

Yes  No  No but ………………………

R9 All referrals will be screened by a qualified OT to ensure the referral is appropriate to the service. The person doing the screening will date and initial that this has been done.

(IP,CP, and Paed)

Q11 has the person screening the referral;

Initialled that this has been done?

Yes  No  No but ………………………

Dated when this was done?

Yes  No  No but ………………………

R10 Where the referral is deemed inappropriate by the person doing the above screen, they will record what action has been taken with the referral. (IP,CP, and Paed)

Q12 Has the action being taken for inappropriate referrals been recorded?

Yes  No  No but ……………………… Not inappropriate 

C1 Consent to Occupational Therapy will be gained prior to the start of the first assessment being carried out, this will be recorded on the Initial Assessment/Interview form. (IP,CP, and Paed)

Q13 Has consent been recorded on the initial assessment form?

Yes  No  No but ………………………

C2 Consent will be gained prior to any action being carried out by the Occupational Therapist and any withdrawal of consent recorded in the relevant case notes. (IP,CP, and Paed)

Q14 If consent has been withdrawn has this been recorded?

Yes  No  No but ………………… consent not withdrawn 

C3 The Occupational Therapist will discuss Occupational Therapy and any intervention with the client prior to recording whether consent was given on the Initial Assessment/interview form. Checking the “consent given” box will imply that the Therapist has had this discussion with the client. (IP,CP, and Paed)

As Q13

C4 Staff will record any written consent to disclose information or document the legal justification for disclosure and record details of the person to whom it has been made. (IP,CP, and Paed) (disclosure means sharing info or reports with other agencies such as social service)

Q15 Has written consent, or legal justification for disclosure been recorded?

Yes  No  No but ………………………

Q16 Has the person to whom the disclosure has been made been recorded?

Yes  No  No but ………………………

A1 All referrals will be screened by a qualified OT to ensure that the referral is appropriate to their service. (As R9 above) (IP,CP, and Paed)

As Q11

A2 A risk assessment will be completed for all community visits and documented on the appropriate form (currently the form entitled “Risk assessment prior to home/community visit”). (IP,CP, Paed, SPD, and specific Home visit procedure audit)

Q17 Has the “Risk assessment prior to home/community visit” been completed for community and home visits?

Yes  No  No but ………………………

A3 For inpatients consent will be gained at initial contact, (see C1) for community patients consent will be checked when making the appointment and recorded on the referral. (IP,CP, and Paed)

For inpatients see Q13

Q18 For community patients is consent recorded on the referral?

Yes  No  No but ………………………

A4 Reasons for discontinuing or not to carry out identified assessments will be recorded in the patients’ notes. (IP,CP, and Paed)

Q19 Are the reasons for discontinuing or not to carry out identified assessments will be recorded in the patients’ notes.

Yes  No  No but ……………… not discontinued 

A5 All OT assessments carried out will be completed using assessments agreed by the service and found in the Powys Occupational Therapy assessment toolbox. (IP,CP, and Paed)

Q20 Are all OT assessments carried out will be completed using assessments agreed by the service and found in the Powys Occupational Therapy assessment toolbox.

Yes  No  No but ………………………

A6 all patients will have an Occupational Therapy plan of intervention drawn up in line with discussed goals and priorities and recorded in their notes. (IP,CP, and Paed)

Q21 Have all patients got an OT plan recorded in their notes?

Yes  No  No but ………………………

I1 All intervention will be documented in the patients case-notes and be in line with the Occupational Therapy plan. (IP,CP, and Paed)

Q22 Is all OT intervention recorded in the patients casenotes?

Yes  No  No but ………………………

Q23 Is this intervention in line with the OT plan?

Yes  No  No but ………………………

I4 Intervention plans will be reviewed regularly and this will be documented in the patients notes, together with any amendments to the plan (IP,CP, and Paed)

Q26 Has it been documented that intervention plans have been reviewed?

Yes  No  No but ………………………

Q27 Have any amendments to the plan been documented in the patients notes?

Yes  No  No but ………………… no amendments noted 

D1 The Occupational therapist will record in the patients notes:

• the patient’s outcome against the pre-set goals (IP,CP, and Paed)

Q28 Has the OT recorded whether the patient has met or not met their goals?

Yes  No  No but ………………………

• the amount of assistance needed for occupational performance (IP,CP, and Paed)

Q29 Has the OT documented the amount of assistance the patient needs to perform occupational performance?

Yes  No  No but ………………………

• recommendations for any ongoing intervention or support required (IP,CP, and Paed)

Q30 Has the OT recorded recommendations for ongoing intervention or support required?

Yes  No  No but ………………………

• recommendations for any assistive equipment and/or environmental modifications (IP,CP, and Paed)

Q31 Has the OT recorded recommendations for any assistive equipment and/or environmental modifications?

Yes  No  No but ………………………

• recommendations for any follow-up, intervention or re-assessment required. (IP,CP, and Paed)

Q32 Has the OT recorded recommendations for any follow-up. Intervention or re-assessment required?

Yes  No  No but ………………………

D2 For inpatients and day hospital patients a discharge summary stating goals achieved and reason for discharge will be recorded in the multi-disciplinary notes; other patients will have a discharge summary included in a letter sent to the referrer. (IP,CP, and Paed)

Q33 Has a discharge summary been written in the notes (in-patient, day patient) or on a discharge letter sent to referrer (other patients)?

Yes  No  No but ………………………

Q34 Does the discharge summary state goals achieved and reason for discharge?

Yes  No  No but ………………………

RK2 Records will follow Powys tHB guidelines and only use approved documentation (IP,CP, Paed and SPD)

Q37 Have OT records followed Powys tHB guidelines?

Yes  No  No but ………………………

RK3 Assessments, reports, referrals and notes will be filed in the Powys tHB approved location within multi-disciplinary notes, and in a logical, chronological way for OT specific notes. (IP,CP, Paed and SPD)

Q38 Have OT assessments etc been filed according to the file key?

Yes  No  No but ………………………

Q39 Are OT notes filed in a logical, chronological way for OT specific notes?

Yes  No  No but ………………………

RK4 All OT intervention recorded will: (IP,CP, Paed and SPD)

• be legible

Q40 are all entries legible?

Yes  No  No but ………………………

• use black ink, or be typed

Q41 are all entries on notes or reports written in black ink or typed?

Yes  No  No but ………………………

• be dated

Q42 are all entries on notes or reports dated?

Yes  No  No but ………………………

• be signed

Q43 are all entries on notes or reports signed by the person doing the entry?

Yes  No  No but ………………………

• use Powys tHB OT service agreed abbreviations only.

Q44 are all abbreviations used on the list agreed by Powys tHB OT service?

Yes  No  No but ………………………

W5 All occupational therapy staff will regularly familiarise themselves with routinely available community loan equipment. This familiarisation will include exact function, weight limit, how it is to be fitted and any need for maintenance. (IP,CP, Paed and SPD)

Q66 Have OT staff consulted the equipment catalogue information on each piece of equipment prior to ordering it?

Yes  No  No but ………………………

W6 All occupational therapy staff who routinely issue community loan equipment should attend a national exhibition of equipment to familiarise themselves with new developments. (IP,CP, Paed and SPD)

Q67 Have OT staff who routinely issue community loan equipment attended a national exhibition of equipment within the last five years?

Yes  No  No but ………………………

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