Authors (including presenting author) :
Chan KH (1), Leung WT(2), Cheng KP(3), CHOY PS(1), Li YC (1)
Affiliation :
1 Department of Family Medicine and General Outpatient Clinic, Kowloon Central Cluster
2 Department of Occupational Therapy, Queen Elizabeth Hospital.
3.Department of Medical Social Services (HA) , Queen Elizabeth Hospital
Introduction :
The Integrated Mental Health Program (IMHP), which is a cross-cluster collaborative mental health service program set up in General Outpatient clinic (GOPC). I was started in Kowloon Central Cluster GOPC since Oct 2011.
Objectives :
The aim of the audit is to ensure quality practice with proper documentation.
Methodology :
• Review the medical record for within 4 weeks from 6/10/2019 to 2/11/2019
• Three auditors involved. One nurse, one social worker, one occupational therapist
• Each auditor randomly selected 20 cases from another discipline for audit in the designed audit period. (e.g. Nurse may check either social worker’s record and occupational therapists record and vice versa)
Result & Outcome :
The overall compliance rate was 97.1%, a 0.1% drop from 2017 results. The "Use GOPC code indicate the referrer" is the criterion with the lowest compliance rate. There is slightly improvement in this year from 86.7% in 32017 to 90% in 2019. Only one criterion achieved a 100% compliance rate. The following is the results per criterion and their analysis.
Analysis of 2019 results:
Question 1: Screening with PHQ 9 & GAD 7
98.3 % compliance rate achieved. One sample skipped this criterion. PHQ-9 is a questionnaire used for determining the level of depression of patients, normally having mental disorders (Kroenke & Spitzer, 2002). The more a client score, the more severe is the depression. On the other hand, GAD-7 is a 7-item Generalized Anxiety Disorder Scale used to determine the anxiety level of a client. Both PHQ-9 and GAD-7 are important tools in determining the mental disorder of a client. Therefore, the clients should be screened for both and the results documented for proper treatment.
Question 2: Essential data and information was captured
The criterion was 98.3 % achieved. Auditors were able to check the essential data included marital status, educational level, occupational level, living environment, finance, and type of contact, referral source, and keyworker's name. The keyworkers were keen on capturing the essential data and information, and its compliance rate remained at 98.3%.
Question 3: Use GOPC code indicate the referrer
90 % achieved. Some sample omitted or used GOPC name to indicate the referrer. The keyworkers should always ensure that they follow the management.
Question 4: Client's condition /problem was addressed
100 % compliance rate achieved. Client's condition/ problem was clearly documented. Clear documentation off the client’s condition is mandatory for the diagnosis and aiding management for the patient. It is also improvement for other keyworkers to follow up the case.
Question 5: Overall management plan was documented
98.3 % compliance rate achieved. Same as documentation of client’s condition, the management allow other healthcare workers to follow up patients property. T
Question 6: Client's outcome was documented.
The criterion was 98.3% achieved. This is the requirement from IMHP manual. It is a show of competence of the keyworkers that managed to document all the client’s outcome (Iyer & Camp, 1999).
Question 7: PHQ 9 & GAD 7 were documented
The criterion was 96.7 % achieved. This is the requirement from IMHP manual. This scores are important information to see the progress of the patient. Omitting the entry may jeopardize follow up the patients
Conclusion:
The overall compliance of the audit is 97.1.7% which was a high standard. The criterion on "Use GOPC code indicate the referrer" was the one with the lowest compliance.. Keyworker should pay more attention on this
