The clinical record review self-audit checklist can be used by practices that are conducting self-assessments in preparation for practice certification processes. The checklist enables doctors, practice nurses and practices to ensure that they are meeting Indicator 10, criterion 10.1 in the College's Foundation Standard:
“The practice ensures all medicines prescribed, administered or supplied are recorded in the Practice Management System (PMS). Medical warnings are noted”.
There are two versions of the clinical record review: One to be completed by general practitioners and one to be completed by nurse practitioners/nurses. Nurse practitioners/nurses can choose either one to complete.
General practitioner clinical record review
Nurse clinical record review