HALABA KULITO GENERAL

HOSPITAL

CHART AUDIT TEAM TOR

Prepared BY: CG & QIU

March, 2014 E.C.

Kulito, South Ethiopia

TITLE

This document shall be referred to as TOR of Halaba Kulito General Hospital Chart Audit Team.
It is prepared to guide the activities of the team established in the Hospital.

INTRODUCTION

Patient medical record documentation is one of the vital aspects of healthcare quality because
hospital data were used for decision making at various level of healthcare
management. Patient medical records are as reference materials for forensic medicine and
evidence-based science.

Standard patient medical record documentation was known as provision for clinical process,
patient quality of care, recognized as source of clinical data for documenting quality indicators
and considered to assist policymakers in several levels healthcare system for monitoring the
burden of medical conditions and compare quality of care by outcomes. Patient medical record
are also used for diagnosis, information sharing and reduce medical errors.

Audit of completeness of patient medical record or chart is crucial to ensure patient medical
record conform with standards of documentation criteria and plan a quality improvement
program as in the standards.

Thus, chart audit team is formed for the established monitoring of completeness of patient
medical record and the team also assists to improve completeness of patient medical record in the
Hospital.

DEFINITION OF TERMS

Medical Record: They are papers that document the care and treatment a patient received.
Completeness of Medical Record: It is the presence of all the necessary information of patients
based on the standard formats attached at the annex and all entries are dated and signed.
Inpatient Medical Record: It is the official record of patient that contains information of
admitted patients to general ward.

Page 1 of 9
Proportion of elements completed of the minimum elements of an inpatient MR.
1. Patient Card (Physician notes) – present and all entries signed
2. Progress note –presented and daily evaluated the Patient
3. Order Sheet – present and daily evaluation
4. Nursing Care Plan – present, at least daily revised and vital sign at least 4 times per day.
5. Medication Administration Record – present and all medications given are signed
6. Discharge Summary – present and signed
7. Clinical pharmacist record chart present and signed
Others that must also be completed based on patient care area and diagnosis
1. Discharge planning form
2. Consultation request and Response form
3. WHO SSI tracking chart for surgical patients
4. WHO trauma chart (for trauma patients)
5. Fluid balance monitoring chart
6. Operation Note
7. WHO SSC
8. Anesthesia chart
9. Patient transfer checklist for surgical patients
10. Different L & D ward charts

GOALS OF THE TEAM

To improve documentation practices and ensure completeness of medical records, so as sharing
of valuable information for continuing of patient care.

Page 2 of 9
OBJECTIVES OF CHART AUDIT TEAM
 To allow quality improvement to take place with ensuring patient medical record
completeness.
 To ensure that clinical audit conducted in the departments of Hospital regularly, as it
leads to sharing valuable information for continuing of patient care.
 To ensure the establishment of quality procedures by medical record audit in which
valuable information is obtained for policy making.

FUNCTION OF THE CHART AUDIT TEAM

 Coordinate all quality improvement activities regarding chart audit to improve proper
documentation practices
 Coordinate the implementation of guidelines, protocols and quality standards related with
patient medical records.
 Ensure adherence to national standards for patient medical records
 Provide recommendations and monitor the implementation of the recommendations at
each department
 Conduct chart audit based on national recommendations.
 To ensure that re-audit conducted to check improvement seen in the gaps or problems
identified in the audit

STRUCTURE AND ORGANIZATION OF CHART AUDIT TEAM

Chart Audit Team Accountability:

 It is accountable to the Hospital Clinical Audit Team (CAT) through the Head of the
Quality Improvement Unit and should report to the CG & QIU Head.
 Has horizontal relationship with other CAT of the Hospital
 Members have individual and joint responsibility for the decisions they pass.

Page 3 of 9
Membership and members of Chart Audit team:
 Rules and procedures for the appointment of chart audit team members is based on
leadership position in the major departments and may include:
o Representation in the clinical department and administration
o Representation from CG & QIU
Structure
 Chair person
 Secretary
 Members

ROLE AND RESPONSIBILITIES

Chair person
 Summarizing and prepare improvement plan for audit gap observed with designing
change ideas
 Leading the chart audit team in the audit program and updating the progress note to the
team
 Should chair meetings and direct the overall function of the team.
 Should take the lead in clarifying the goals the team meeting.
 Responsible for coordinating the team activities.
 Ensure that regular audit and re-audit conducted
 Is member of the Hospital CG & QIU
 Should ensure that regular meetings take place and should convince extraordinary
meeting whenever necessary.
 Must ensure that meeting are conducted in a professional manner and are constructive for
both the hospital and the team
Secretary
 In collaboration with the chair person, prepare agendas schedule meetings and notify
team members
 Should distribute the agenda by ensuring all necessary documents requiring discussions
or comments are attached to the agenda at least three day prior to the meeting

Page 4 of 9
  Should prepare minutes of each meeting, as summary of discussions and all action points
with the name of the responsible individual.
 Should prepare and circulate all pertinent materials for meetings to all members and their
task team prior to the meeting
 Ensures that the decisions taken and audit findings by the Chart audit team are submitted
to the CG & QIU and HMIS unit for notification and report
 Follow up the action plan of the team

Members
 Attend ordinary and extraordinary meetings ,respecting the team
 Accept and implement a decision passed by the majority of chart audit team
 Prepare for each meeting by reading agendas, minutes of previous meeting and other
documents distributed for consideration
 Actively participates in the audit activities and function of the committee
 Propose issues, ideas, suggestions that need to be discussed to strengthen the team
 Demonstrate professional competence through active participation in the meeting

FREQUENCY OF MEETING
 The team should meet regularly once in 3 months and four meetings are expected to be
conducted per year.
 Extraordinary meeting may be convened should a matter of particular importance arise
 Such meeting will be convened upon decision of the chairperson ,or if called for by a
minimum of one-third of members

DECISION MAKING
Decision by the chart audit team should be made by majority vote, but in the case of a tie
the chairperson has deciding vote.
The criterion for full quorum is greater or equal to 50% of Chart audit team members
Decision for routine activities can be done by two or more chart audit team members and
communicated to other members

Page 5 of 9
 Decision making will be based on consensus of the committee members, based on
scientific evidence whenever applicable.
Recommendations of chart audit team shall be presented to the hospital SMT or Hospital
Quality Committee
This document should be kept as permanent records of the Hospital
All chart audit team recommendations should be disseminated to the medical staff and
other concerned parties and authorities in the Hospital.
The minute shall be checked by the chairman and accepted by team members as a true
and accurate at the commencement of the next meeting.

MONITORING AND FOLLOW UP OF CHART AUDIT TEAM

PERFORMANCE

 Chart audit team should monitor the activity report of committee on every meeting
 Chart audit team secretary should ensure regular meeting is conducted and all
members are attending every committee meeting.

CAT TOR APPROVAL

This TOR of chart audit team have been drafted and prepared by the Hospital Quality Unit on
20/7/2014 E.C. as per national recommendations, will be discussed and approved by the team
meeting.

AMENDEMENTS
This term of reference shall be reviewed annually from date of approval. It may be altered to
meet the current needs of the MOH and Hospital by the agreement of the majority of the chart
audit team members.

Page 6 of 9
LIST OF CHART AUDIT TEAM MEMBERS FOR HALABA KULITO GENERAL

HOSPITAL

No Name Profession Position in the Team Sign

.
1 Dr. Degisew Desalegn GP Head

2 Mr. Hussein Nasir HO Secretary

3 Dr. Henok Mengesha GP Member

4 Mr. Hussein Abiso BSC Nurse NM Director

5 Dr. Beshir Birhanu GP Member

6 Dr. Tariku Eshetu GP Member

7 Mr. Abduselam Nasir Clinical Pharmacist Member

8 Kindie Getachew BSC Nurse Member

Page 7 of 9