Since mid-2020, ASeTTS Leadership has focused on developing quality assurance and continuous improvement practice and culture within the organisation. This work has involved the development of policies and guidance, delivery of training, and the review, development, implementation and embedding of practices across services. Over this period significant energy and time has been invested into improving client record management, treatment planning and review, and data entry.
ASeTTS’ requires that a client file is created for each client. The protection of client privacy and confidentiality is a guiding principle in the collection, use and storage of ASeTTS client information. Client files are an important source of information about client’s health, social needs and treatment planning. ASeTTS understands that client files enhance safety and continuity of care by the accurate recording of client details and history, and is committed to ensuring that information in client files is complete, accurate and relevant.
Annual File Audits provide an opportunity to monitor if our staff are effectively developing, maintaining, reviewing, retaining, securing and archiving client files, and maintaining records of care and treatment in a professional and confidential manner. File audits are a useful way to:
- Demonstrate that quality and compliance is taken seriously.
- Gather meaningful statistics.
- Identify and mitigate risks.
- Identify corrective actions, including areas for staff training, clinical governance, and policy and procedure reviews.
- Ensure staff have the correct levels of supervision in place, clearly guided by Policy.
In late 2022, the Executive Manager Client Services and Senior Counsellors completed a structured and planned audit of ASeTTS client files.
The audit demonstrates that actions taken to improve client record management, treatment planning and review, and data entry have had a positive impact on practice. While some expected areas for improvement were identified, it is noted that the audit shows strong performance and improvement.
The following findings were noted by the auditing team:
And following recommendations are made to support ongoing improvement of practice: