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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