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Table 2 Final set of audit items in the youth health audit tool

From: Monitoring and assessing the quality of care for youth: developing an audit tool using an expert consensus approach

Audit Item

Measure type

Likely documentation in client record

Frequency of reporting

General Information

 Current Medicare number recorded

Process (documentation)

Client summary

On first presentation

 Date of birth

Process (documentation)

Client summary

On first presentation

 Sex

Process (documentation)

Client summary

On first presentation

 Indigenous status

Process (documentation)

Client summary

On first presentation

 Mature minor assessment

Process (client centred)

Service items

First time client presents without parent/guardian

Attendance

 Date last attended

Process (service delivery)

Client summary

Routinely

 Follow-up if no attendance within 24 month

Process (service delivery)

Client summary

Every 24 months

 Reason for last attendance

Outcome

Client summary

Routinely

 Seen by Aboriginal Health Practitioner

Process (client centred)

Events

Routinely

 Documentation of other regular primary healthcare services attended

Process (documentation)

Service items or progress notes

As required

Key health information

 Documented long term health conditions

Process (documentation)

Client summary

On diagnosis

 If yes, documentation of a management plan

Process (service delivery)

Progress notes

Every 24 months

 Evidence of child/adult health check (MBS 715)

Process (service delivery)

Medicare billing

Annually

 Evidence of alternative child/adult health check

Process (service delivery)

Client summary

Annually

 Evidence of youth health check

Process (service delivery)

Client summary

Annually

 Consent for health check

Process (client centred)

Service item

As part of annual health check

Immunisations

 Completed immunisation chart/record

Process (service delivery)

Immunisations

As indicated

 Hep B

Process (service delivery)

Immunisations

As indicated

 HPV

Process (service delivery)

Immunisations

As indicated

 VZV

Process (service delivery)

Immunisations

As indicated

 DTPa

Process (service delivery)

Immunisations

As indicated

 Influenza

Process (service delivery)

Immunisations

As indicated

 Pneumococcal

Process (service delivery)

Immunisations

As indicated

Protective factors, risk factors, brief interventions and referral

 Tobacco use

Process/outcome

Risks or service items

As part of annual health check or opportunistically

 Tobacco use actions taken

Process (service delivery)

Risks or service items or recalls

As indicated

 Tobacco use actions reviewed (within 3 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Tobacco use report received from referral agency (within 6 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Alcohol use

Process/outcome

Risks or service items

As part of annual health check or opportunistically

 Alcohol use screening tools

Process (documentation)

Risks or service items

As part of annual health check or opportunistically

 Alcohol use actions taken

Process (service delivery)

Risks or service items or recalls

As indicated

 Alcohol use actions reviewed (within 3 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Alcohol use report received from referral agency (within 6 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Other substance use

Process/outcome

Risks or service items

As part of annual health check or opportunistically

 Other substance use screening tools

Process (documentation)

Risks or service items

As part of annual health check or opportunistically

 Other substance use actions taken

Process (service delivery)

Risks or service items or recalls

As indicated

 Other substance use actions reviewed (within 3 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Other substance use report received from referral agency (within 6 months)

Process (service delivery)

Risks or service items or recalls

As indicated

 Sexual activity and risk discussion

Process/outcome

Service item or progress notes

As part of annual health check or opportunistically

 Sexual risk behaviour actions taken

Process (service delivery)

Service items or recalls

As indicated

 Sexual risk behaviour actions reviewed (within 3 months)

Process (service delivery)

Service items or recalls

As indicated

 Sexual risk behaviour report received from referral agency (within 6 months)

Process (service delivery)

Service items or recalls

As indicated

 Mental health assessment

Process/outcome

Service items

As part of annual health check or opportunistically

 Mental health assessment screening tools

Process (documentation)

Service items

As part of annual health check or opportunistically

 Self harm and suicide discussion if risk factors present

Process (service delivery)

Service items

As indicated

 Mental health, self harm or suicide risk actions taken

Process (service delivery)

Service items or recalls

As indicated

 Mental health, self harm or suicide risk actions reviewed (within 3 months)

Process (service delivery)

Service items or recalls

As indicated

 Mental health, self harm or suicide risk report received from referral agency (within 6 months)

Process (service delivery)

Service items or recalls

As indicated

 Lifestyle discussion

Process (service delivery)

Risks or service items

As part of annual health check or opportunistically

Scheduled services

 BMI for age and gender

Process/outcome

Service items

As part of annual health check

 Waist circumference

Process/outcome

Service items

As part of annual health check

 Weight and waist actions taken

Process (service delivery)

Service items or recalls

As indicated

 Oral health check

Process/outcome

Service items

As part of annual health check or symptomatically

 Oral health action taken

Process (service delivery)

Service items or recalls

As indicated

 Ear/hearing check

Process/outcome

Service items

As part of annual health check or symptomatically

 Ear health/hearing actions taken

Process (service delivery)

Service items or recalls

As indicated

 Cardiac auscultation (heart check)

Process/outcome

Service items

As part of annual health check or symptomatically

 Heart health actions taken

Process (service delivery)

Service items or recalls

As indicated

 Skin exam

Process/outcome

Service items

As part of annual health check or symptomatically

 Skin health actions taken

Process (service delivery)

Service items or recalls

As indicated

 Blood pressure

Process/outcome

Service items

As part of annual health check

 Blood glucose test

Process/outcome

Service items

As part of annual health check

 Blood glucose action taken

Process (service delivery)

Service items or recalls

As indicated

 Pap smear

Process/outcome

Service items

As part of annual health check

 Pap smear action taken

Process (service delivery)

Service items or recalls

As indicated

 Sexual health check

Process/outcome

Service items

As part of annual health check or symptomatically

 Sexual health actions taken

Process (service delivery)

Service items or recalls

As indicated