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 |