Page 79 - C:\Users\ToRiM\Desktop\New folder2\

Appendix 11: Clinical Audit Guidelines in Health Clinic

Introduction:

Clinical audit for AMS is a tool that looks into details in clinical practice by individual health care
provider that prescribed antibiotic and overall trend of prescription by health clinic. This can be
further used for quality improvement cycle that involves assessment of the effectiveness of clinical
services against agreed standards of best practice.

Stage of implementation:

STAGE 1 - PREPARATION:
• Done annually by random sampling of minimal 30 case notes as samples or as needed
whenever there are issues in the trend of antibiotic prescription.
• Identify available resources, e.g. audit team headed by FMS in charge of health clinic.
• Existing guidelines defining desired standards as reference, such as NAG and clinical
pathways.
• Define criteria: All antibiotic prescription on any health care provider to be randomly selected
with minimum of 30 record within the past 1 month.

STAGE 2 - MEASURING LEVEL OF PERFORMANCE:
• Data collection maybe from computerised records or manual collection. Data entered in
excel format with embedded formulas.
• Audited clinical record will be scored based on criteria of best practice with score of 80%
and above would be consider as appropriate.
• Analyse the data collected:
o Compare actual performance with the set standard based on previous scoring.
o Discuss how well the standards were met.
o If the standards were not met, note the reasons for this.

STAGE 3 – MAKING IMPROVEMENTS:
• Present the results and discuss them with the relevant individual or teams in the -organisation.
• The results should be used to develop an action plan, specifying what needs to be done, how
it will be done, who is going to do it and by when.

STAGE 4 - MAINTAINING IMPROVEMENTS:
• This follows up the previous stages of the audit, to determine whether the actions taken have
been effective, or whether further improvements are needed.
• It involves repeating the audit (i.e. targets, results, discussion); hence the terms “audit cycle”.

Any adhoc audit for individual prescriber or health clinic performance in AMS prescription
performance can be done when necessary throughout the year. Data can be used for self-
monitoring audit that does not require any report submission.

Second Edition 2022 | Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities 77