Key Words 655

Audit, cystic fibrosis,

physiotherapy, standards,
quality.
Do Physiotherapy Records by Lynne Gumery
Meet Professional Standards? Joanne Sheldon
Helen Bayliss
Commitment to good practice and improved patient Roisin Mackle
care through audit within the Birmingham David Stableforth
Heartlands Adult Cystic Fibrosis Centre David Honeybourne
Christine Reade

Summary Audit was performed to assess physiotherapy documentation within the adult cystic fibrosis unit at
Birmingham Heartlands Hospital, against nationally accepted standards compiled by the Chartered Society of
Physiotherapy (1993) and the Association of Chartered Physiotherapists in Respiratory Care (1994). Through
their involvement with clinical audit, healthcare professionals derive benefits for themselves, by increasing their
knowledge and understanding of effective practice, thus enhancing the effectiveness of the care they deliver.
Audit was initially completed between December 1998 and January 1999 using the medical notes of all 43
adult cystic fibrosis patients admitted to the hospital. Physiotherapy documentation was assessed using a
proforma designed by the authors. Results of audit concluded that the ‘gold standard’ of 100% completion
rate was not met for all criteria of documentation. Recommendations were implemented before re-auditing.
These included improving professional standards awareness via a programme of in-service training for all staff,
development of local standards, and piloting the development of a new pre-printed assessment sheet.
The audit loop was completed by re-auditing six months after initial audit to reassess the effect of
recommendations.
Documentation was re-audited for all 43 patients admitted between July and August 1999.
Results showed that for registration details, 11 out of 12 sections scored 93% or greater completion rates in
audit 2 compared with 5 out of 12 in audit 1. There was improvement in completion within 9 out of 12
(75%) of categories (2%-53% range of improvement).
All categories of subjective assessment scored 84% or above completion rate in audit 2 compared to 5 out
of 7 categories in audit 1. Improvement was noted in 4 out of 7 categories (range of improvement 7%-21%)
in audit 2.
The objective assessment showed 11 out of 14 sections scored 90% or above in audit 2 compared to 8 out
of 14 in audit 1. Improvement in 11 out of 14 categories (78%) demonstrated a range of improvement from
2% to 61% in audit 2. For any test not completed or requested it is recommended that this be documented.
It was recommended that all areas of assessment should be completed within 24 hours of referral.
All 43 physiotherapy records displayed a treatment plan, and 95% of patients’ notes demonstrated ongoing
evaluation in audit 2 compared to 93% in audit 1. Of all entries made, 99% in audit 2 were signed compared
with 95% in audit 1. 97% were dated in audit 1 and 99% in audit 2. A discharge summary was completed in
77% of all notes in audits 1 and 2.
Regular in-service training for all on-call staff will continue to ensure awareness of documentation standards.
Re-audit in 12 months will evaluate implementations after audit 2 – the use of a new pre-printed assessment
form and development of a CF physiotherapy care pathway. The aim is to achieve the 'gold standard' of 100%
completion rate for documentation, ensuring ongoing commitment to provision of improved patient care
through audit.

Gumery, L, Sheldon, J, Bayliss, H, Mackle, R, Stableforth, D,

Honeybourne, D and Reade, C (2001). ‘Do physiotherapy records meet
professional standards? Commitment to good practice and improved
patient care through audit within the Birmingham Heartlands adult cystic
fibrosis centre’, Physiotherapy, 86, 12, 655-659.

Physiotherapy December 2000/vol 86/no 12

 656
Authors
Lynne Gumery MCSP
is a clinical specialist
in physiotherapy and
Jo Sheldon BSc MCSP
and Roisin Mackle
BSc MCSP are senior
physiotherapists.
They were responsible
for data collection
analysis, writing and
editing this paper.
Helen Bayliss BSc
MCSP is a senior
physiotherapist who
helped with writing
and data collection.
David Stableforth MA
FRCP and David
Honeybourne MD
FRCP are consultant
respiratory physicians
specialising in cystic
fibrosis. They were
editor in chief and
editor respectively.
Christine Reade of
the clinical audit
department helped
with data analysis.
All authors work in
the adult cystic
fibrosis centre at
Birmingham
Heartlands Hospital.
This article was
received on
December 6, 1999,
and accepted on June
16, 2000.
Address for
Correspondence
Lynne Gumery, Adult
Cystic Fibrosis Centre,
Ward 12, Birmingham
Heartlands Hospital,
Bordesley Green,
Birmingham B9 5SS.
Physiotherapy December 2000/vol 86/no 12
Introduction
Audit is a cyclical process that evaluates the
effectiveness of clinical care against agreed
standards or guidelines with the sole aim of
improving services for patients (Tobin and
Judd, 1998). This audit was developed to
evaluate the effectiveness of physio-
therapists‘ adherence to the standards doc-
umentation of the Association of Chartered
Physiotherapists in Respiratory Care
(ACPRC) and the Chartered Society of
Physiotherapy (CSP). Patient care can only
be optimised by clear, accurate docum-
entation (CSP, 1993).
Audit can improve documentation prac-
tice and hence improve the quality of patient
care and demonstrate a commitment to
good practice. Healthcare professionals can
gain through the undertaking of clinical
audit by increasing their knowledge and
understanding of effective practice, thereby
improving the effectiveness of the services
they provide (Tobin and Judd, 1998).
To meet legal requirements to optimise
patient care, clear and accurate docu-
mentation is required (CSP, 1993). In
response to demand, nationally accepted
‘Standards of Physiotherapy Practice’ (CSP,
1993) and ‘Standards for Respiratory Care’
(ACPRC, 1994) were developed, distributed
and implemented.
The purpose of this study was to assess by
audit the adherence to the professional
standards of the CSP and ACPRC by all
members of the physiotherapy department
working within the adult cystic fibrosis (CF)
unit, maintaining a 24-hour, seven-day week
service.
Lack of time, manpower and support for
audit have been widely documented as
barriers to undertaking audit (Robinson,
1996; Morrell et al, 1997; Cheater and
Keane, 1998; Tobin and Judd, 1999). Time
was allocated to undertake work involved in
this audit and support given by senior staff
and the clinical audit department.
Methodology
The samples consisted of the physiotherapy
records contained within the medical single-
patient records of all adult cystic fibrosis
patients admitted to Heartlands Hospital
during December 1998 and January 1999
(audit 1) and July and August 1999 (audit
2). This resulted in 43 patients being
identified in both audits 1 and 2.
A proforma was developed by the authors
to assess the records against selected criteria
developed from the CSP and ACPRC
standards for documentation, assessment,
treatment planning and evaluation.
Recommendations made following audit 1
were implemented prior to audit 2,
including the development of a new pre-
printed physiotherapy assessment form
and the development of care pathways for
cystic fibrosis. Results were compared and
analysed. Data were scanned using Formic
Software and analysed using Microsoft Excel
by the clinical audit department.
Results
The proforma facilitated the assessment of
completion rate of documentation by
chartered physiotherapists in four main
categories: registration details, subjective
assessment, objective assessment and
treatment planning and evaluation.
Registration Details (fig 1)
In audit 2, 11 out of 12 categories scored a
93% or greater completion rate compared
with 9 out of 12 scoring above 84% in
audit 1.
The completion of telephone number
had increased from 12% in audit 1 to 65%
in audit 2. The rate of completion had
improved but it was possibly completed less
frequently because the information was
easily obtained from other sources.
Recommendation Full registration details
should be completed within 24 hours of
referral. This was omitted from the new
printed assessment form specific to the
Adult CF Unit, Birmingham Heartlands
Hospital.
Subjective Assessment (fig 2)
All categories were completed in excess of
84% of the time in audit 2 and improvement
was evident in 4 out of 7 categories
(presenting complaint, family history, drug
history and chest radiograph). Range of
improvement was 7% to 21%. The greatest
increase was for completion of chest
radiograph results, from 47% in audit 1 to
86% in audit 2. The section for recording
chest radiograph was completed 86% of the
time, but when the scores for unavailable or
not requested chest radiographs were
subtracted the score was 53% completion
rate. This was compared with 33% in audit 1.
The physiotherapy assessment is completed
within the first 24 hours of referral. If a chest
radiograph has not been done or is
unavailable it should be documented
as such.
Professional articles 657

Audit 1 Audit 2
100

90

80

70
Percentage

60

50

40

30

20

10

0
PID Surname Forename Address Tel no DoB DoA Ward Physio Clinical Reason Consultant
diagnosis for
referral

PID Patient identification number

DoB Date of birth
DoA Date of admission

Fig 1: Were the following registration details completed in the

physiotherapy records?

Recommendation Full subjective Audit 1 Audit 2

100
assessment should be completed within
24 hours of referral. 90

Objective Assessment (fig 3) 80

This section comprises 14 separate 70

categories of which 12 scored 88% or
greater completion rate in audit 2 compared 60
Percentage

with 10 out of 14 in audit 1. Two categories 50

scored below 88% in audit 2: shortness of
breath (81%) and capillary blood 40
gases/arterial blood gases (30%). When
30
observing the results for blood gases they
appear low (9% in audit 1 and 30% in audit 20
2). However, when combined with scores for
10
'unavailable ' or 'not requested' blood gas
results this would collectively mean an 0
increase in completion of 32% in audit 1 PMH HPC PC SH FH DH CXR
and 93% in audit 2. Often these tests are not PMH Past medical history FH Family history
necessary if a patient has adequate oxygen HPC History of presenting complaint DH Drug history
PC Presenting complaint CXR Chest radiograph
saturations and has not been noted to be in SH Social history
respiratory failure. It is recommended that
this be documented. Fig 2: Were the following subjective assessment details completed?
Overall there was an improvement in
objective assessment in 11 out of 14
categories (79%) with a range of improve-
ment between 2% and 61%.

Physiotherapy December 2000/vol 86/no 12

 658

Audit 1 Audit 2
100

90

80

70

60

Percentage 50

40

A/E Air entry

SoB Shortness of breath 30
FiO2 Fraction of inspired oxygen
CBGs/ABGs Capillary/arterial blood gases 20

10
Fig 3: Were the following objective
assessment details completed? 0
A/E Crackles Sputum SoB FiO2 Spirometry Mobility
Expansion Wheeze Cough Exercise Oxygen CBGs/ABGs Equipment
tolerance saturation

Recommendation Full objective assessment

should be completed within 24 hours of
referral.

Treatment Planning and Evaluation (fig 4)

100% of patient notes displayed a treatment
plan evident in both audits. Ongoing
assessment and evaluation were evident in
95% of patient notes in audit 2 and 93% in
Audit 1 Audit 2 audit 1.
100
Recommendation Treatment plan and
90
ongoing assessment and evaluation should
80 be evident in all patient records.
70
99% of patient notes were signed and dated
60 in audit 2 compared with 95% in audit 1.
Percentage

50
Recommendation All patient notes are to
40
be signed and dated after each entry.
30

20
The ‘gold standard’ of 100% completion
rate was not met for all criteria. Improve-
10
ment in completion of 27 out of 38 cat-
0 egories (71%) was observed. No change
Treatment plan Evaluation Signed entries Dated entries Discharge
summary
occurred in 7 out 38 categories (18%).
Deterioration was seen in 4 out of 38
Fig 4: The 43 case notes were assessed to determine if treatment plans were categories (11%). In audit 2, 7 out of 38
present and how many entries were signed and dated categories (18%) showed a 100% comp-
letion rate compared with 5 out of 38 (13%)
in audit 1. Overall, a 90% and greater comp-
letion rate was observed in 29 out of 38
categories (76%) in audit 2 compared with
21 out of 38 (55%) in audit 1.

Physiotherapy December 2000/vol 86/no 12

Professional articles
Recommendations
Recommendations implemented after audit
1 were:
■ Local in-service training on the
importance of maintaining standards and
their implementation.
■ Copies of the CSP and ACPRC standards
should continue to be given to all new
members of staff before starting on-call
duties or working within the adult cystic
fibrosis unit.
■ Copies of national standards should
continue to be displayed on office and
staff room noticeboards.
■ Local standards specific to the adult CF
unit should be developed and distributed.
■ A new pre-printed physiotherapy
assessment form should be developed.
■ A care pathway for physiotherapy
management of CF and an integrated
care pathway for CF should be developed.
References
Association of Chartered Physiotherapists in
Respiratory Care (1994). Standards for
Respiratory Care, CSP, London.
Chartered Society of Physiotherapy (1993).
Standards of Physiotherapy Practice, CSP, London,
2nd edn.
Cheater, F, and Keane, M (1998). ‘Nurses'
participation in audit: A regional study’,
Quality in Health Care, 7, 27-36.
Morrell, C, Harvey, G and Kitson, A (1997).
‘Practitioners based quality improvements:
review of the Royal College of Nursing’s
dynamic standard setting system’, Quality in
Health Care, 6, 29-34.
Robinson, S (1996). ‘Audit in the therapy
professions: Some constraints on progress’,
Quality in Health Care, 5, 206-214.
659
Following audit 2 these recommendations
were upheld and the following further Key Messages
recommendations were added: Audit can lead to:
■ Physiotherapy records should be ■ Increased
re-audited in 12 months’ time. knowledge and
understanding of
■ The authors will present findings of the effective practice.
audit locally and later nationally.
■ Increased
effectiveness of service
Conclusion provision.
The quality of physiotherapy record doc-
umentation has been improved through ■ Improved practice.
audit. Increased knowledge and under-
standing has led to a demonstration of ■ Improved quality of
commitment to good practice and increased patient care.
effectiveness of service provision within the
adult cystic fibrosis unit at Birmingham ■ Demonstration of
Heartlands Hospital. Further recommend- commitment to
ations have been made and re-audit will take evidence-based practice
(Tobin and Judd,
place in 12 months to complete the audit
1998).
loop. Future implementation of research-
based clinical guidelines and recommend-
ations made from current research findings
will ensure commitment to evidence-based
practice. This will be a progression for
future audit.
Tobin, A and Judd, M (1998), ‘Understanding
the barriers’, Physiotherapy, 84, 11, 527-529.
Tobin, A and Judd, M (1999), ‘Experiencing
the barriers’, Physiotherapy, 85, 1, 6-10.
Bibliography
Association of Chartered Physiotherapists in
Respiratory Care (1989). Guidelines towards
good practice in respiratory physiotheray, ACPRC,
London.
Birmingham Heartlands and Solihull NHS
Trust Report (1998). Audit of the use of the new
medical record folder, BHS Trust, Birmingham.
Birmingham Heartlands and Solihull NHS
Trust Report (1998). Audit of record keeping
standards BHS Trust, Birmingham.
Chartered Society of Physiotherapy (1994).
General principles of record keeping, Information
paper 20, CSP, London.
Physiotherapy December 2000/vol 86/no 12