Data are often held in several databases, on paper or electronically, or may not be collected at all. If the required data are not collected routinely, a specific paper or electronic encounter sheet can be devised for healthcare professionals to record additional information during each consultation (NICE 2002). However data should not be recorded merely for audit purposes, if it has no clinical or organisational value as a result of its utilisation in the audit process.
Data for an audit are generally collected retrospectively, in other words some time after care has been provided. Typically, the data are collected from records, and may be extracted onto standard forms or entered directly into a computer database. The time period of the data extracted should be agreed in advance. The period should be one when average or typical activity occurred (e.g. beware looking at waiting times when there has been significant holiday or sickness absence (although either might be a legitimate reason for examining waiting times), recording prescriptions for antihistamines in the middle of winter (out-with the hay-fever season))
Remember to ensure confidentiality of individual patient data at all times (see Caldicott Principles) AND only collect information that is required.
Where is the data to be found? (Usually the data will be found in the electronic clinical record)
- Electronic practice data (Clinical records / QoF)
PCQIS have developed audit templates designed to support practices to record the information required for monitoring a range of services including those around enhanced services. Where provided, templates offer a consistent approach to the recording of data both in terms of the types of data required to support processes of care, and in the method of recording based as they are on a common set of READ Codes.
Other sources including
- External data (LHB / Secondary or Community care)
- Manual patient records
- Practice activity analysis (appointments etc)
- Surveys (Patient satisfaction)
- Direct observation