1

Contents
Acknowledgment...................................................................................... i
Acronyms...............................................................................................................................................ii
Foreword..............................................................................................................................................iii
Part One - Clinical Audit Guide
1. Introduction.....................................................................................................................................2
Background............................................................................................................................................2
Rationale.................................................................................................................................................3
2. Definitions........................................................................................................................................5
Quality Improvement......................................................................................................5
Clinical Audit.....................................................................................................................5
Quality Committee/Counsel..........................................................................................5
Quality unit/directorate.................................................................................................5
Quality improvement team............................................................................................5
3. Objectives........................................................................................................................................6
4. Scope..................................................................................................................................................6
5. Conducting clinical audit............................................................................................................6
6. Stages of clinical audit.................................................................................................................6
Planning.................................................................................................................................7
Selecting Quality Standards and Setting Criteria.................................................................10
Defining standards and criteria....................................................................................................11
Setting target 13
Inclusion criteria/exclusion criteria...........................................................................................13
Exceptions 13
Measuring Performance against Standards...........................................................13
Data Collection 14
Data analysis Step.............................................................................................................................15
Drawing conclusions.........................................................................................................................16
Presentation of results.....................................................................................................................16
AUDIT METHODOLOGY FOR SELECTED NATIONAL
DISEASE PRIORITIES............................................................................17
Making improvements..................................................................................................22
Sustaining the improvement.......................................................................................23
7. Audit Monitoring Process.......................................................................................................24

Audit status indicator definition...........................................................................24

8. Roles and responsibilities...................................................................................................25
MoH 25
Sub national (RHB, Zonal, district).........................................................................................25
Health facility..................................................................................................................................25
Healthcare Providers..........................................................................................25
Quality Improvement team.........................................................................................................26
Quality unit/directorate...............................................................................................................26
Partners 26
9. References.................................................................................................................................27

Part TWO - Clinical Audit Tools for National Priority Conditions

Maternal Health Audit tools.........................................................................................................28
Audit Tool: ANC......................................................................................................................28
Audit Tool: labour and delivery.........................................................................................32
Audit Tool: ENC......................................................................................................................37
Audit Tool: Postnatal.............................................................................................................42
Audit Tool: PPH.......................................................................................................................45
Audit Tool: Sepsis...................................................................................................................49
Audit Tool: Pre-eclampsia....................................................................................................53
Audit Tool: CS..........................................................................................................................58
Audit Tool: CAC......................................................................................................................62
Audit Tool: FP..........................................................................................................................66
Neonatal and Child Health Audit tools.....................................................................................69
Audit Tool: Preterm care......................................................................................................69
Audit Tool: Hyperbiluribinimia.........................................................................................77
Audit Tool: PNA......................................................................................................................85
Audit Tool: Neonatal Sepsis.................................................................................................94
Audit Tool: SAM....................................................................................................................102
Audit Tool: AGE....................................................................................................................108
Audit Tool: Pneumonia........................................................................................................113
Audit Tool: Malaria..............................................................................................................119
Audit Tool: HEI follow-up care.......................................................................................124
Audit Tool: [Link] follow-up care...........................................................................128
Communicable Diseases Audit tools.........................................................................................134

Audit Tool: Pneumonia.......................................................................................................134

Audit Tool: TB Initial care................................................................................................140
Audit Tool: TB Follow-up care.........................................................................................150
Audit Tool: [Link] Initial care.................................................................................156
Audit Tool: [Link] follow-up care...........................................................................163
Non- Communicable Diseases Audit tools..............................................................................170
Audit Tool: HTN initial care.............................................................................................170
Audit Tool: HTN follow-up care......................................................................................175
Audit Tool: DM initial care...............................................................................................181
Audit Tool: DM follow-up care........................................................................................187
Audit Tool: DKA....................................................................................................................194
Audit Tool: Asthma initial care........................................................................................200
Audit Tool: Asthma follow-up care.................................................................................205
Mental Health Audit tools............................................................................................................211
Audit Tool: Schizophrenia initial care...........................................................................211
Audit Tool: Schizophrenia follow-up care....................................................................215
Audit Tool: Depression initial care.................................................................................218
Audit Tool: Depression follow-up care..........................................................................223
Audit Tool: Substance use disorder initial care........................................................226
Audit Tool: Substance use disorder follow-up care..................................................231
Emergency and Critical care Audit tools...............................................................................234
Audit Tool: Triage.................................................................................................................234
Audit Tool: Poisoning..........................................................................................................236
Audit Tool: Trauma..............................................................................................................242
Audit Tool: ICU.....................................................................................................................248
Audit Tool: Burn...................................................................................................................253
Nursing and Midwifery Audit tool............................................................................................261
Audit Tool: Nursing and midwifery care......................................................................261
Surgical-Anesthesia care Audit tool........................................................................................268
Audit Tool: Surgical-Anesthesia care...........................................................................268
Annex.................................................................................................................................................277
Annex 1 List of Contributors.....................................................................................................277
Annex 2 Clinical audit proposal form....................................................................................281
Annex 3 Clinical audit project registration and monitoring form...............................286
Annex 4: Clinical audit finding reporting template..........................................................287
Acknowledgment

This Document- Hospital clinical audit guide and tools- has been developed with the lead-
ership and coordination role of the Health Service Quality Directorate, Ministry of Health- Ethio-
pia, and the involvement of key stakeholders. Throughout its development, stakeholders within and
outside the ministry of health have contributed, including Clinical Service Directorate, Maternal &
Child Health Directorate, Disease Prevention and Control Directorate, Emergency and Critical Care
Directorate, WHO, and hospitals. Experts with ample experience in clinical audit, senior clinicians
with subject-matter knowledge on identified topic areas, and experts from the program division of
the selected priority areas were engaged. A committee composed of professionals from the afore-
mentioned stakeholders was established to lead the revision and development process. Additionally,
the feasibility of the audit tools was tested, helping make the necessary amendments based on the
feedback obtained from the pilot.

The zeal, dedication, and collaboration shown by all experts involved were exceptional. The
insightful inputs given by all experts helped in laying down the groundwork and enriching the doc-
ument. The Ministry of Health highly appreciates the efforts and initiatives of the entire members of
the development team. The list of contributors is found in Annex 1.

Finally, we appreciate WHO Ethiopia for the technical and financial support in the editing
and printing of the document.

i
Acronyms
AaBETH Addis Ababa Burn, Emergency and Trauma Hospital
CSD Clinical Service Directorate

CRC Compassionate and Respectful Care

DPC Disease Prevention Directorate

ED Emergency Department

EICCD Emergency, Injury and Critical Care Directorate

EPHCG Ethiopian Primary Health care Clinical Guideline

HFIP Healthcare Finance Improvement Program

HSQD Health Service Quality Directorate

HSTQ Health Service Transformation in Quality

HSTP Health Sector Transformation Plan

LMICs Low and Middle Income Countries

MCHD Maternal and Child Health Directorate

MoH- Ethiopia Ministry of health-Ethiopia

NA Not Applicable

NICU Neonatal Intensive Care Unit

NQS National Quality Strategy

NQSS National Healthcare Quality and Safety Strategy

PDSA Plan- DO- Study- Act

QI Quality Improvement

QIT Qulaity Improvement Team

RAND/UCLA Research and Development/University of California at Los Angeles

RHB Regional Health Bureau

STG Standard Treatment Guidelines

WHO World Health Organization

ii
Foreword

MoH-Ethiopia has been making substantial efforts to improve the quality of health services
provided in health facilities across the country. These efforts mainly focused on introducing proven
and globally accepted strategies and interventions at service delivery point to detect and address
gaps in quality.

During the implementation of the first Health sector transformation plan (HSTP), 2008-2012
EFY, improving the quality of healthcare w as among the transformation agenda. To operationalize the
HSTP-I, MOH-Ethiopia developed and implemented the national healthcare quality strategy. The
strategy established the quality management system in every healthcare administration and care de-
livery area. Additionally, during the execution of the strategy a number of quality cadres have been
trained and they have designed and implemented several quality improvement projects. Similarly, in
the HSTP-II improving the quality of healthcare is among the priorities and to materialize the plan
MoH developed and introduced the National healthcare quality and safety strategy in which devel-
oping well functioning clinical audit system is one of the strategic initiatives put forward. The other
achievement that the ministry attained was the development of different clinical guidelines like
EPH- CG, STG, and protocols that provide comprehensive information/algorithms to the care
provider in the evaluation and management of a patient. The development of such guidelines helped
standardize the care delivery in health facilities across the country, giving the precondition to
initiate clinical audit practice in hospitals and health centers.

The health services quality directorate (HSQD) also strived to introduce the practice of clin-
ical audit in the country’s health system. Accordingly, the directorate developed and launched the
HSTQ document in 2016, which included a clinical audit guide and audit standards for selected
topic areas. Following this, many hospitals started to utilize the tools and conduct clinical audits.
With all its defects, HSTQ played a vital role in creating awareness and familiarizing leaders,
quality improve- ment officers, and frontline HCWs with the process of clinical audit to some
degree.

After the introduction of this document, a significant number of hospitals gradually

absorbed the concept. Hospitals started conducting audits quarterly on some or all priority areas
included in the HSTQ, devising action plans for the identified gaps and reporting the result (average
score) to the ministry. While this is a great achievement on its own, observations obtained during
supportive super- visions, review meetings, and coaching sessions reveal notable gaps. The practice
of linking gaps to a quality improvement project, monitoring the implementation of the designed
action plan, re-auditing to assure whether changes resulted in improvement, and producing audit
reports is weak. In addition, the perception among healthcare workers is that the task is left to the
QI unit when in principle; it should be the responsibility of every healthcare professional working in
the service being audited.

iii
Accordingly, this document is developed in a way it can address the gaps seen during the
implementation of HSTQ. It focuses on the process of clinical care, avoiding inputs. And within the
clinical care process, it targets the crucial steps whose unfulfillment contributes to the utmost share
of morbidity and mortality. The design has tried to simplify the audit process in terms of
understanding the standards and criteria and collecting and analyzing the data. The audit tools
included in the docu- ment can be utilized to easily assess the appropriateness of day-to-day clinical
care delivered within hospitals. Moreover, consideration was given to who, where, and the time it
takes to conduct the au- dits. It is a result of multiple consultative workshops that involved different
stakeholders and experts who are actively working in the service delivery and quality improvement
activities at the hospital level. It aimed to design a simplified tool tailored to the practice of health
care delivery in hospitals that will ultimately excel the practice of clinical audit and pave the way
for the improvement of the quality of clinical care.

The document has two main sections. The first section is a clinical audit guide that depicts
the concept, principles, method, and cycle of clinical audit. It describes international definitions of
clini- cal audit, details of each five steps of clinical audit including how to select and set
criteria/standards, and how these concepts can be applied in health facilities whenever clinical
auditing is planned and conducted. The second section comprises audit tools for prioritized topics
which have been devel- oped from relevant guidelines through consultative workshops with a wide
range of stakeholders and experts. The document also includes forms and templates expected to be
used in the different stages of the audit process, namely audit proposal form, audit registry form,
and audit reporting form. These templates are introduced in this document in an attempt to forge the
practice in line with best practice.

Thus, it is with confidence I say that this document will ignite and strengthen the institution-
alization of high quality, effective, and regular clinical audit practice within hospitals to help
identify gaps in quality of care and bridge those gaps to realize a better health outcome of decreased
morbidity and increased patient experience.

I would like to call upon all stakeholders; hospitals, professional associations, implementing
partners to work for the betterment of the clinical services and institutionalization of quality culture
by promoting the regular clinical audit.

Dr. Hassen Mohammed

Director, Health Services of Quality Directorate

iv
1
1 Introduction
Background
In the past six years, the Ministry of health-Ethiopia has been working rigorously to ensure
the quality and safety of healthcare. The major undertakings that have been implemented are; the
for- mulation and execution of two national quality strategies, the establishment of a quality
management structure across the health system, the extensive capacity building in healthcare quality
improvement, and the creation of public awareness of the high-quality healthcare system.
Moreover, a common understanding of the importance of high-quality healthcare for the realization
of universal health coverage has been created.

During the implementation of the two quality strategies, several large-scale quality improve-
ment initiatives have been launched and encouraging results were noted. The Ethiopian Hospitals
Alliance for Quality is one of the initiatives that utilized quality concepts for the improvement of
care delivery and outcomes. In the last three cycles, there has been a massive engagement of
hospitals and recognition of the best performers. The Maternal and Neonatal Health quality, equity,
and dignity (MNH-QED)-WHO-led Global initiative- that mainly operates by networking health
facilities in the learning Woredas has been implemented for the last three years. Within this
initiative, forty-eight (48) facilities were networked to reduce maternal and neonatal mortality by
half and the QI approach has been employed to achieve the goal. Furthermore, other small-scale
initiatives that aimed to improve the HIV and Hypertension quality of care have been undertaken
paving the way for more strong ini- tiatives.

To facilitate the learning and knowledge transfer, local and national level learning platforms
have been organized. Among them, the National Healthcare Quality and Safety Summit takes a
bigger stake bringing healthcare policymakers, academicians, partners, and professional and patient
associ- ations aboard to discuss the improvement strategies, to share the experience, and to take a
common stance for improvement of the care delivery.

Although fragmented and not uniformly done, the ministry established a system of
producing different clinical guidelines and protocols that can help health care providers treat their
patients with evidence-based knowledge. Numerous clinical protocols and treatment guidelines
have been devel- oped and disseminated by different bodies within and outside the ministry of
health, which paved the way for effective and standardized care across the country.

To help the implementation of HSTP-I, the health services quality directorate (HSQD) pre-
pared clinical audit guidelines incorporated in a document called ‘health sector transformation in
quality-HSTQ’. The document guided the quality improvement methods and structure, clinical audit
process, and set quality standards on national quality strategy disease priorities and other selected
areas like data quality and patient safety and CRC.

2
Despite all these efforts, the health systems lacks a robust clinical audit system at the
hospital level. The recency of the concept, lack of clearly established role and responsibility from
ministry to facility level, absence of well-devised clinical audit system, shortage of well-capacitated
profes- sionals (on clinical audit) at the facility level, and the complexity and bulkiness of the
current audit tools utilized at the facility level are some of the contributing factors to the slow
progress toward best practice in clinical audit in the country. Therefore, establishing a solid clinical
audit program that uses the available clinical guidelines is highly required to substantiate the
improvement efforts.

Rationale
A growing body of research shows that there is a significant quality gap in the provision of
health care along one or more quality dimensions- people-centeredness, safety, timeliness,
effective- ness, efficiency, equity, and integration. Actions to improve the quality and safety of care
provided require the introduction of a well-organized effective clinical auditing program as one
component.

The review of best practices focused on the English NHS(National Health Service) -
pioneers in incorporating the clinical audit practice into contemporary healthcare improvement -
showed that for clinical audit programs in health facilities to be successful two components need to
be fulfilled; i.e., the use of appropriate methodologies and creating a supportive environment.
Accordingly, appli- cation of appropriate methods in terms of meticulous planning, designing of
easy and workable audit standards and criteria, designing and monitoring of appropriate quality
improvement plans based on identified gaps, linking audit findings with quality improvement
projects(systematic management of change) together with the absence of appropriate structure that
can organize and provide the neces- sary support for auditors to building their capacity on designing
and execution of effective clinical au- dits are among the prevailing limitation in the clinical audit
practice in the Ethiopian Health system. Moreover, The inaccessibility of quality data because of
poor data recording practice, the bulkiness of the data set required for audit bearing weight on the
staff that is burdened with other priorities are other deficiencies. Also, the absence of a policy and
strategy at the ministry level that defines the roles and responsibilities of stakeholders and sets a clear
path towards the establishment of an effective clinical audit system made the practice fall far behind
the best practices. Nevertheless, encouraging results have been seen in the practice of clinical audits
in hospitals; QI teams are making efforts to regularly conduct audits using the tool and plan actions
based on findings. Recognition and accep- tance by healthcare providers and QI teams at the facility
level are increasing.

Strengthening and intensifying the efforts of clinical audit practice initiated at a hospital
level to excel from a mediocre stage to an optimal level and serve as a means for quality
improvement is of paramount importance.

3
Informed by the best practice, this document outlines the concept of clinical audit, steps
in conducting a clinical audit, roles, and responsibilities of involved stakeholders, and methods to
evaluate the effectiveness of the clinical audit program. Moreover, based on the available clinical
guidelines and protocols utilized in hospitals by involving relevant stakeholders, simplified clinical
audit tools on selected topic areas are developed and included to facilitate the regular conduction of
clinical audits in hospitals. The audit tools comprise standards and criteria that can be used to assess
the appropriateness of the clinical service delivered in hospitals. Therefore, this guide and tools will
direct, standardize, and improve the effectiveness of the clinical audit practice in the Ethiopian
health system.

4
2 DEFINITIONS

Quality Improvement
Quality improvement (QI) is a continuous process where by organizations iteratively test
and measure changes in work routines, set and achieve ambitious aims, shift whole system
performance, and spread best practices for rapid uptake at a larger scale to address a specific issue
or set of issues they have determined to improve (1).

Clinical Audit
‘‘A quality improvement process that seeks to improve patient care and outcomes through a
systematic review of care against explicit criteria and the implementation of change” (2)

It involves the assessment of structure, process, and outcome of care against agreed explicit
standards where changes are introduced based on identified gaps and further monitoring made to as-
certain improvements (2).

Quality Committee/Counsel
A committee that is composed of department heads and selected experts in the hospital that
oversees the quality improvement efforts of the hospital and mainstreams the QI concepts and activ-
ities in all departments.

Quality unit/directorate
A formally organized structure that is responsible for the coordination and guidance of all
QI activities in a hospital. This unit or directorate involves in devising the hospital QI strategy,
annual QI plan, providing capacity building trainings related to QI, coordinating the formation of
quality improvement teams (QITs), coordinating regular clinical audit projects, providing coaching
support to QITs, lesson documentation, selection of key performance indicators related to service
quality, involving in research, planning and conducting learning sessions etc…

Quality improvement team

Is a team that works in the specific unit/ward responsible for designing, implementing,
moni- toring, and reporting quality improvement activities. This team functions as an audit team.
This team carries out the day-to-day QI activities and should be composed of representatives of
different profes- sionals involved in the care process within the department. The roles and
responsibilities of the QIT and members, meeting frequency, and quorum need to be defined in a
terms of reference.

5
3 Objectives

The objectives of this guide are to:

 Strengthen the clinical audit system in hospitals across the country.

 Standardize the clinical audit practice in such a way that it’s an integral part of
mainstream QI activities.
 Help hospitals to effectively conduct a clinical audit on the services they deliver.
 Guide the development of audit standards and criteria for local audit priorities.

4 Scope

This document is intended to guide healthcare workers, quality improvement teams, and unit
leaders practicing in a hospital setup to understand the concepts and methodologies of clinical audit
and conduct clinical audits as an integral part of mainstream clinical and QI activities. It promotes
awareness on clinical audit and guides to the achievement of best practices in clinical audit in hospi-
tals.

5 Conducting clinical audit

An effective clinical audit requires a structured system with competent leadership, involve-
ment by all staff, and stress on team working and support (3). Therefore, hospitals should integrate
the healthcare clinical audit to the larger improvement effort (if it exists) or develop a clinical audit
program.

6 Stages of clinical audit

A typical clinical audit has five stages: planning, standard selection, and criteria setting, mea-
suring performance against a standard, making improvement, and sustaining improvement.

Fig.1. Stages of clinical audit

6
Planning
Although the amount of preparation depends on the circumstance, whether it is a small audit
conducted by an individual or a large audit involving multiple disciplines effective planning and
preparation is key for a successful audit (3).

Preparation involves three main components: involving stakeholders, determining audit

topic, and planning the delivery of audit field work (3).

Step 1: involving stakeholders

Three questions can guide to determine who should be involved in clinical audits: who is
involved in the delivery of care, who receives, uses, or benefits from the care or service, who has
the authority to support the implementation of any identified changes (3).

Since clinical audits evaluate the effectiveness of clinical care practices and the majority of
these involve multi-disciplinary teams, the involvement of representatives of all clinical and
manage- rial practices contributing to the audit topic area is crucial. Everyone involved should be
made clear of the aim of the audit and their specific role and responsibilities. An agreement for the
leadership and ownership should be reached and where possible commitment for change by all
involved should be ascertained (3).

Departments within the facility should establish a QIT (which will also serve as an audit
team) that consists of all relevant stakeholders for the improvement of the care within the unit. It
may be composed of representatives of all involved in the care provision i.e., clinicians (physician,
midwife, nurse, laboratory, and pharmacy professionals) and unit leaders/coordinators,
administration staff, and other health personnel.

The primary concerns of those receiving care might differ from those delivering care
therefore the audit team should give careful thought to the possible benefits of involving service
users in the clinical audit process and which methods to use if they are to be part of the audit.
Service users can be directly involved in the audit or indirectly through focus group discussion,
interviews, surveys, col- lecting feedback, and the likes. Where service users are directly involved
in clinical audit programs, their roles need to be clearly defined and appropriate support and
guidance provided to enable the delivery of the audit (3).

Attaining the buy-in of those with authority to approve changes arising from audit recom-
mendations is also important, especially in circumstances where the changes need a resource or
have implications for other services areas (3).

7
Step 2: Determine the audit topic

Careful thought should be given when selecting audit topics as hospitals have limited re-
sources with which they can execute clinical audits. The audit teams should do this with the view
of improving the quality and safety of care. Apart from mandatory audits (national audits prioritized
by MoH), all other audits should be prioritized in a way resource can be utilized efficiently (3). The
following factors should be taken into account when prioritizing audit topics

 costly practice areas

 areas with a frequent patient complaint
 high-volume practice areas
 risky practice areas
 areas that show variation in clinical practice,
 have evidence of poor quality (high rate of complication and adverse outcome)
 have a reliable data source
 likely to improve process and outcome care

It is also good to consider whether there is good evidence to inform audit standards and if
data can be collected in a reasonable time (3).

Audits that are part of national audits should be a top priority. The hospital/department will
then prioritize other topic areas using a scoring system taking into account the above points. It
should be noted that there is also room for carrying out audits on the clinical interest of practitioners
(3).

After topic selection, audit proposal should be prepared and submitted to the QI unit (Annex
2: Audit proposal form), QI unit/ committee approves the proposed audit after thorough review. Ap-
proved proposals should be registered using the registration form to facilitate monitoring of
progress. (Annex 3: Clinical audit project registration and monitoring form)

Step 3: Planning the audit delivery

Planning the audit execution is a very crucial step for a successful audit. The following
issues should be well considered in this step.

a. Set the aim/objectives of the audit: Carrying out an audit with no clear objective will
bring little to no improvement. Detailed statements can be used to describe the
differ- ent aspects of quality that will be measured to show how the aim of the
clinical audit will be met (3).

8
E.g.

DM Audit topic- Diabetic Routine

Care

Aim- to improve the quality of outpatient clinical care provided

to diabetic patients during follow-up

Objectives-

 Ensure patients on diabetic follow-up are appropriately evaluated

 Ensure relevant investigations are performed
 Ensure patients receive appropriate treatment
 Ensure patients are given proper counseling
 Ensure patients with indication are referred to higher institution

Assure all team members are aware of the purpose: All Health workforce involved in the
subject of the audit must understand the aim of the audit and their role in it. This need s to be
clarified at the outset and may be expressed in terms of the reference document (3).

b. Equip the audit team with the necessary knowledge and skills: Involving the right
people with the right skill will be a crucial aspect of the planning process ensuring
the task will be accomplished effectively and efficiently. The audit team should have
a great depth of understanding of clinical audit processes. Members should know the
concept of clinical audit, and clinical guidelines utilized in clinical care. They have
to be familiar with setting criteria , data collection, templates used in clinical audit
(audit proposal form, chart abstraction forms….), data analysis methods, and
methods for improving. The QI unit will be responsible for building the capacity of
the QIT in the aforementioned areas; it will also provide technical support whenever
necessary.

9
Skills required in clinical audit process (3)
 Leadership, organizational and management skills
 Clinical skills
 Project management skills
 Change management skills
 Audit methodology expertise
 Understanding of data protection requirements
 Data collection and data analysis skills
 Facilitation skills
 Communication skills
 Interpersonal skills
Adapted from A practical guide to clinical audit August 2013 Dublin

c. Providing the necessary structures

Completed proposal form along with relevant standards, audit tools, and other forms
should be prepared and submitted to the QI unit for approval before the audit begins. This is
necessary to ensure all aspects of the audit have been considered. Resources needed to
cascade the audit should be mapped and made available. This issue should be raised and
communicat- ed through the appropriate line of governance structure. The mechanism for
progress tracking, reporting to the appropriate lead, and a clear timeline in which the audit
will be designed and conducted should be defined in the structures (3).

Selecting Quality Standards and Setting Criteria For the selected

national disease and condition priorities, use the audit standards and criteria attached in the second
section of the document. These standards and criteria are developed after con- sidering the current
context of health care delivery in hospitals across the country. The working com- mittee has
thoroughly discussed and weighed the quality culture, the structure in place, and lessons learned
from the implementation of HSTQ. Over and above that, great efforts were made to make the
audit criteria suitable for all tier levels.

Once a department/hospital meets these standards, the QIT can devise audit standards and
criteria that are more advanced or prioritize other audit topics, develop standards and criteria for the
identified topics, and continue with the process of clinical audit and improvement. The QIT can for-
mulate evidence-based and relevant criteria using the guide below.
The quality standards or criteria developing process should take the internationally validated
methodology and these should be included in the audit proposal for approval by the quality commit-
tee.
10
Defining standards and criteria

Standard
“An objective with guidance for its achievement given in the form of criteria sets
which specify required resources, activities, and predicted outcomes” (Royal College of
Nursing, 1990) (4).

Criteria
“An item or variable which enables the achievement of a standard (broad objective of
care) and the evaluation of whether it has been achieved or not” (Royal College of Nursing,
1990) (4).

Within clinical audit, criteria are used to assess the quality of care provided by an in-
dividual, a team, or an organization. These criteria are explicit statements that define what is
being measured and represent elements of care that can be measured objectively (5).

Criteria can be classified in to three- structure criteria, process criteria, outcome criteria (2).

Structure criteria
Structure criteria refer to the resources required. They may include the numbers of
staff and skill mix, organizational arrangements, the provision of materials, drugs, equipment,
and physical space (2).

Process criteria
Process criteria refer to the actions and decisions taken by practitioners together with
users. These actions may include communication, assessment, education, investigations, pre-
scribing, surgical, and other therapeutic interventions, evaluation, and documentation (2).

Outcome criteria
Outcome criteria are typically measures of the physical or behavioral response to an
intervention, reported health status, and level of knowledge and satisfaction. Sometimes
surro- gate, a proxy, or intermediate outcome criteria are used instead. These relate to aspects
of care that are closely linked to eventual outcomes but are more easily measured (2).

11
Developing valid criteria
Once a topic has been chosen, appropriate criteria that are explicit, evidence-based,
measurable, and related to important aspects of care must be developed (2).

Methods for developing criteria

1. Using guidelines: criteria can easily be drawn out from recommendations of up-to-date
clinical practice guidelines. A literature search of the specific journal can also be used to
develop criteria when national or locally endorsed guidelines are unavailable (2).
2. Prioritizing the evidence method: start by conducting systematic reviews to identify
key elements of care. Then carry out focused systematic literature reviews about each
key element of care to develop, when it is justified by evidence, one or more criteria for
each element of care. This is followed by prioritization of the criteria into ‘must do’ or
‘should do’ based on the strength of research evidence and impact on outcome. Present
the criteria in a protocol including data collection forms, and instructions to external
peer review (2).
3. RAND/UCLA appropriateness method: The method applies presenting findings of a
literature review to a panel of clinicians, chosen for their clinical expertise and profes-
sional influence, who are asked to rate the appropriateness of a set of possible criteria
for the particular procedure on a 9-point scale from 1 (extremely inappropriate) to 9
(extremely appropriate). The first round of ratings is undertaken without allowing any
discussion between the panelists, and a second-round is undertaken after a structured
panel meeting (2).
4. Criteria based on professional consensus: criteria can also be developed based on the
views of professional groups, applying methods of formal consensus. However,
different consensus groups are likely to produce different criteria. A checklist is useful
to ensure that an explicit process is used to identify, select, and combine the evidence
for the crite- ria and that the strength of the evidence is assessed in some way. Such
criteria have the advantage of taking local factors such as the concerns of local users
into account (2).
5. Involving users: Service users can also become usefully involved in developing criteria
that take account of the needs of people with their particular condition, from specific
age groups, or ethnic or social backgrounds. Audit teams can collaborate with users to
establish their experience of the service and the important elements of care from which
criteria can be developed. If the criteria selected by clinicians and those selected by
users relate to different elements of care, both sets of criteria may be included. If
clinicians and users have different views about the same element of care, an open
approach is required to achieve consensus (2).

While developing standards or criteria it should be noted that the criteria/ standards
should be in line with the SMART protocol. Each criterion should be clear, easy to understand
(un- ambiguous), specific (not open to interpretation). They also should be measurable-
feasible

12
to attain the data for, achievable- of a level of acceptable performance agreed with
stakeholder, Relevant (related to important aspects of care), and theoretically sound
(evidence-based). Ac- ceptable evidence-based guidelines that are going to be used to
formulate the criteria should be identified ahead.

Setting target

Audit criteria should consist of quantifiable performance levels. These performance lev-
els or targets: a defined level or degree of expected compliance with the audit criterion may be
expressed as percentages (0% to 100%). Clinical importance, practicability, and acceptability
should be taken into account and assessed when setting targets. Where a criterion is critical to
the safety of service users, targets may be set at 100%. However, where clinical importance is
not as significant, resources required to fulfill the target performance level should be
considered and an acceptable performance level (one which is seen as both reasonable and
attainable by those delivering and receiving care) should be identified. Setting an ideal target
also requires identifying the best possible care that lies between the minimally acceptable
level of care and the highest possible level of care (3).

Inclusion criteria/exclusion criteria

To make the data collection purposeful and ascertain the representativeness of the
target population, it is advised to set inclusion and exclusion criteria. Inclusion criteria are
statements describing the “target population to whom a clinical guideline is intended to
apply”, While ex- clusion criteria are used to “Define areas outside the remit of the clinical
guideline” (3).

Exceptions

Refers to a group of cases within the target population for which the criterion is not
ap- plicable. There will be acceptable circumstances in which the identified sample may not
comply with a specific criterion. These samples will not be included in the data analysis for
that specific criterion. It should be noted that an agreement should be reached on exception
before the audit commence (3).

Measuring Performance against Standards

This stage has the following four steps: data collection, data analysis, drawing conclu-
sions, and presentation of results (3).

13
Data Collection
This is the collection of relevant data about the current practice to facilitate
comparison. Before data collection commences, a structured approach should be taken to the
identification of relevant data and to ensuring that the data collection process is efficient,
effective, and accu- rate. Details that need to be established from the outset include, the user
group to be included, inclusion/exclusion criteria, the consent required to access user group
information, the health- care professionals involved in the service user’s care, the period over
which the criteria apply, the analysis to be performed (2).

Points to be considered before data collection begins

 What type of data do I need to collect (quantitative and/or qualitative)?
 What data items will need to be used to show whether or not
perfor- mance levels have been met for each standard?
 What data sources will be used to find the data?
 Will a data collection tool need to be designed?
 Will I need to collect data prospectively and/or retrospectively?
 What size is the target population and will I need to take a sample?
 How long will data be collected (manually and/or electronically)?
 How long will it take to collect the required amount of data?
 Who will be collecting the data?
 How will I ensure data quality?

Adapted from Ashmore, Ruthven and Hazelwood (2011b). (3)

The type of data required is dependent on the audit question and objectives. The aim
of data collection is to enable comparison of current practice against the audit standard; there-
fore, the type of data collected must facilitate this comparison. Data types can be of
categorical (nominal/ordinal) and quantitative or numerical (discrete/continuous) (3).

Data items
Data collected must be relevant to the aims and objectives of the audit. It is equally
important that each data item is adequate and not excessive for the purpose of measurement of
practice against the relevant audit criteria. Collection of data which is not required for the pur-
poses of measurement provides little or no benefit, is more time consuming and may infringe
compliance with information governance requirements and practices (3).

14
Sources of data
The source of data for an audit should be specified and agreed by the audit team. The
source specified should provide the most accurate and complete data as readily as possible.
As much as possible data that is relevant and routinely collected and can be found in existing
sources should be used for auditing. In times where the data in question is not documented in
existing source a method of tracing the data from other far reached sources can be attempted
(3).

Data collection methods:

Can be retrospective/ cross sectional / prospective. Retrospective data is collected after
the completion of care to the service use while prospective data is collected in real time
during the care provision (3).

 Sample selection methods

More often than not clinical audits involve the technique of sampling as it is not
necessary or even feasible to take data on all target population identified. One major factor
that should be taken in to account when sampling is that, the sample should be representative
of the target population. There are various methods of sampling but the commonly used are
random sampling and convenience sampling (3).
Random sampling is a simple method of sampling where service users are selected
randomly for instance every 3rd, 6th case seen (3).
Convenience sampling uses the approach of selecting the nearest and most convenient
persons to act as respondents; it there fore does not produce findings that can be taken to be
representative (3)

 Sample size
Clinical audit is not research. It is about evaluating compliance with standards rather
than creating new knowledge, therefore, sample sizes for data collection are often a
compromise between the statistical validity of the results and pragmatic issues around
data collection i.e., time, access to data, costs. The sample should be small enough to allow
for speedy data collection but large enough to be representative. In some audits the sample
will be time driven and in others it will be numerical (2).

Data analysis Step

Data collection is only part of the process of measuring performance, in order to
compare actual practice and performance against the agreed standards, the clinical audit
data must be

15
collated and analyzed. The basic aim of data analysis is to convert a collection of facts (data)
into useful information in order identify the level of compliance with the agreed standard (3).

The basic requirement of an audit is to identify whether or not performance levels

have been reached. This requires working out the percentage of cases that have met each audit
cri- terion. In order to calculate the percentage, it is necessary to identify both the total
number of applicable cases for a criterion (the denominator) and the total number within the
denominator group that met the criterion (the numerator) (3).

Drawing conclusions
After results have been compiled and the data has been analyzed against the standards,
the final step in the process (where applicable), is to identify the reasons why the standard
was not met. In order to understand the reason for failure to achieve compliance with clinical
audit criteria, the audit team should carefully review all findings. Individual cases where care
is not consistent with criteria should be reviewed to find any cases which may still represent
acceptable care. Cases of unacceptable care should then be reviewed in order for the team to:
clearly identify and agree on areas for improvement identified by the clinical audit. Analyze
the areas for improvement to identify what underlying, contributory or deep-rooted factors are
involved (3).

There must be a clear understanding of the reasons why performance levels are not
being reached to enable development of appropriate and effective solutions. There are a
number of tools that can be utilized to facilitate a root cause analysis, including process
mapping, the ‘five whys’, and cause and effect diagrams (fishbone diagramming) (2, 3).

Presentation of results
The aim of any presentation of results should be to maximize the impact of the clinical
audit on the audience in order to generate discussion and to stimulate and support action
planning. There are various methods for the presentation of clinical audit results including
visual presentations, for example, posters which are useful ways of reaching as many
stakeholders as possible. Data can also be presented visually using tables, charts and graphs in
both written and verbal presentations (for example, through using presentation software like
Microsoft PowerPoint), Written reports (Annex 4: Audit finding reporting template) for
submission to the relevant clinical lead, directorate or governance committee and Verbal
presentations at relevant meetings (3).

16
AUDIT METHODOLOGY FOR SELECTED NATIONAL
DISEASE PRIORITIES
The description below illustrates the methodology that should be followed while
auditing the selected topics in a hospital setup. The hospital clinical audit tools are designed
for selected priority topics within a thematic area. The sub-teams tasked with the development
were guided to use a prioritization matrix for the topic selection process. The audit tools
were developed through successive consultative workshops involving experts with subject
matter knowledge and programmatic experience in selected topic areas. Where available, the
developing committee attempted to find and stick to the latest version of national guidelines
while synthesizing the criteria, as these guidelines dictate the service provision in a hospital
setup. International guidelines targeting low and middle-income countries (LMICs) are
utilized where it was difficult to find national or local recommendations.

The audit tools are structured in a way that can make the audit process easy. An audit
tool for a specific topic includes the general aim of the audit- “to improve the quality of
clinical care on that specific topic”, which is further broken down into multiple objectives
covering the steps in the clinical care process. “Aim” and “objectives” will create a uniform
understanding among the audit team as to why the audit is being conducted. Following these,
“inclusion” and “exclusion” criteria, which the auditors will use to determine the study
populations from the source population, are identified. The instruction section that outlines
additional points the audit team should follow is also described.

The “Standards” -are labeled in a light green color and describe and assess the critical
clinical steps a client passes through, from evaluation to treatment to monitoring to counseling
and discharge at the point of care. “Criteria” which quantify a specific standard are listed
under each standard.
Some of these criteria will have “sub-elements”-which quantify the criterion under
which they are listed. These “sub-elements” are shaded in blue and are requirements for
fulfill- ment of a criterion.

The last standard (which is found at the bottom of the the audit tools) is an outcome
standard that measures the result of the clinical care. It is found in most audit topics, except
those without an immediate outcome (ANC, postnatal care, CAC, initial care aspects of DM,
HTN, Asthma, TB and HIV/AIDS and HEI).

Each outcome and process standard is followed by a target, which denotes the
expected level of performance. These targets, expressed in percentage), serve as a reference
point against which the actual performance is compared.

17
Data collection methods
 The data collection source is mainly the client chart. Registry review may be appropriate
when assessing some criteria in some audit topic areas like ENC, TB, and HIV/AIDS…).
The specific data source the auditor must look for within a client chart or registry is
identi- fied in the data source section of the table.

 A total of 19 medical records (client chart) of the last reporting quarter should be sampled
for the audit. The individual client charts can be withdrawn by systematic random
sampling (total number of cases seen in the last completed quarter divided by 19 will give
the Nth value; take medical record number (MRN) of charts every Nth value).

 Use the available client charts drawn for the last reporting quarter as 100% even if the
num- ber of client charts found for the reporting quarter is less than 19.

 For follow-up care audit topics, unless specified on the standard/criterion, assess the care
provided during the three-month period. For instance if the patient had three visit in the
quarter, assess the care provided during all three visits. If a time period is specified on the
standard or criterion, assess the care provided during the specified time period.

 Use the data abstraction tool and identify the data element for the audit.

 To verify whether a criterion, a sub-element, or an outcome standard is met or not, look

for the data element in the specified data source and confirm whether the step is
completed or not.

 Absence of documentation is taken as the service was not provided.

 On multiple occasions, triangulation of data from multiple data sources is needed to make
verification that the step stated in the criterion or a sub-element is fulfilled. The descrip-
tions provided in the data source section of the table indicate which data to triangulate and
which data sources to look for in the patient chart or registry. If the triangulations reveals
inconsistencies the criterion or a sub-element will be considered unmet and will be scored
“NO” and “0” respectively.

 To ease the burden on the auditing team, for audit topics with monitoring components of
admitted or kept patient care, a review of a couple of days’ data will be considered suffi-
cient to assess the clinical care. The instruction section (top of the table) of the audit tools
describes the specific days that will be reviewed during the audit.

18
 Each standard will be scored from 100%. The percentage will be calculated based on the
number of criteria met out of the expected. For instance, the standard will be scored 100%
if all criteria under it (excluding the NA) are fulfilled. It will be scored 50% if two of the
crite- ria out of the four are fulfilled and it will be scored 75% if three out of four criteria
are met.

 The outcome standard, which is the last standard within the audit tools assessing the result
of the clinical care, will be scored “YES” or “NO”. N.B. some audit topics do not have an
outcome standard (ANC, postnatal care, CAC, initial care aspects of DM, HTN, Asthma,
TB and HIV/AIDS and HEI).

 In the soft copy version of the audit tools, the score for a standard per chart is
automatically calculated. If the audit team is using a hard copy, they need to determine
the score for a standard using the above explained method.

 If all requirements for a criterion are met, score “YES”, if any requirement is unmet score
“NO”, If the criterion does not apply for the specific patient, record it as NA (not applica-
ble).

 For a criterion that has sub-elements under it, give “1” if the sub-element is fulfilled, and
give “0” if it is not fulfilled or give NA if it does not apply for the particular patient. The
criterion will be scored “YES” if all sub-elements (excluding the NAs) are scored “1” oth-
erwise it will be scored “NO”

 Use the remark section to document any additional information or reminders during data
collection.

19
Peculiarities
The audit tool for malaria should be utilized in areas where malaria is endemic. If the
audit team was not able to find a single case of admission due to malaria during the audit period,
they can skip the audit for malaria.
On adult health and child health themes, when conducting the audit on pneumonia, the
target population is the patients who have been admitted and cared for in the ED initially and
then transferred to the inpatient ward. The upper section of the audit tools assesses the immediate
care that should be provided in the ED, while the latter focuses on the follow-up care that is
provided in the inpatient department.
On the adult health section, when auditing the topic TB follow-up care, the audit team
should review the care provided for the patient starting from the end of the second month till end
of six month. The patient is expected to be evaluated weekly by the provider in this phase.
An audit on TB follow-up care should be conducted if the facility provides a follow-up
service for TB patients. If the facility doses not have a follow-up service for TB patients, this
section can be skipped. N.B. this does not include the audit on TB initial care. The audit on TB
initial care should be done by all hospitals.
Whenever there is a description next to a criterion or standard, the auditor must give
attention to the description and score the criterion or standard accordingly. For instance
whenever the auditor comes across a description saying “only for primary hospitals” it means
that criterion or standard only applies to primary hospital context; the criterion or standard will
be scored “NA” for General and tertiary hospitals.
When analyzing clinical audit findings and designing QI projects on emergency topics
(Poisoning, Burn, and Trauma), the audit team should keep the national target for emergency
room mortality in mind (which is 0.2%). In addition to comparing the score of the outcome
standard for each topic with the outcome target, the audit team should also calculate the
aggregate ER mortality rate of the hospital from all emergency causes and identify the degree of
contribution of the three causes toward the aggregate mortality rate. The audit team can then
design QI projects with interventions that can help decrease the total emergency mortality rate by
focusing on the three causes. This ideology is based on the fact that, in an emergency room, the
initial components of the care for most cases are similar and interrelated. Therefore, having a
holistic view of the care provided in ED is crucial to improve the overall outcome.

20
Data Analysis

 Each process standard will be scored from 100%. The percentage will be calculated based
on the number of criteria met out of the expected. For instance , the standard will be scored
100% if all criteria under it (excluding the NA) are fulfilled. It will be scored 50% if two of
the criteria out of the four are fulfilled.

 Once the score of the standard for each chart is determined, calculate the actual
performance (average score) of the 19 charts or total number of charts audited. This is
calculated by add- ing the score of the standard for each chart and dividing it by 19 or total
number of charts au- dited. Again in the soft copy version of the audit tools the score is
calculated automatically. When using the hardcopy version one has to calculate the score
manually.

 Compute the difference between the performance (average score) and target in terms of
per- centage. This is calculated as (100%*actual performance)/Target.

 Calculate the average score for the outcome standard by dividing the number of charts that
are scored ‘YES’ to the total number of charts audited, if the outcome standard is in the
form of positive statement or by dividing the number of charts that are scored ‘NO’ to the
total number of charts audited, if it is stated in negative form. N.B some topic areas do not
have an outcome standard.

 The “total” at the bottom of the table on the X-axis denotes the total number of process
standards met per chart. N.B. The outcome standard should not be included in this count.
Calculate the percentage on the X-axis for a single chart by counting the number of process
standards that are met (meaning achieving the target) by a single chart divided by the
number of process standards expected to be met by a single chart (excluding the outcome
standard). A standard is considered met when the chart scores a point that is equal or above
the target set for the standard.

 The general average (of the all reviewed charts) on far right of the X-axis can be computed
by the summing average score of each chart and dividing it by the number of charts
audited.

 In the soft copy version of the audit tools, each of the above discussed scores are calculated
automatically (the excel sheet generates the results automatically). When using the
hardcopy version, one has to calculate the scores manually using the method described
above.

21
Drawing conclusion

 Identify the standards on which there is significant difference between set target and
actual performance. These are the areas which need to be addressed first.
 Do problem analysis using five whys and fishbone analysis and other tools.
 Identify the root cause of the gap.
 When the difference between the performance and set target continues to be more than
100%, it indicates that a revision of the set target is needed.

Presentation of results and writing report

 Present the findings to staff and relevant stakeholders.

 Write a report (Annex 4: Audit finding reporting template) and submit it to the
responsible body (facility manager, case team leaders, process owner, QI unit, etc.)
 Regular summary clinical audit reports, together with recommendations, should be com-
municated to all relevant areas of the organization. An effective audit carried out in one
area of the institution may be transferable to other parts of the organization. Once a round
of data collection has been completed and the data has been analyzed, the results and
findings should be presented at quality meetings, for discussion, agreement of
interventions, and a commitment to complete another audit cycle within a designated
timeframe. The quality committee will review all summary clinical audit reports on
completion.

Making improvements

The ultimate goal of conducting clinical audits is, understanding the degree to which
care provided comply with the expected level of care and identify poor areas of performance
to make improvements in those areas (3).

Data analysis and interpretation, which lead to a conclusion, will answer the question
of degree of compliance, thereby pointing to areas of excellence and areas of poor
performance. QIT should interpret the data and discuss the findings to identify areas of poor
performance that need improvement action (3).

After a thorough analysis of root causes the next step is to come up with possible
chang- es or recommendations that can address the areas which need improvement. The audit
team is expected to develop such changes and these should be presented to all relevant
stakeholders

22
where a thorough discussion regarding the feasibility, urgency, impact on clinical care and
service users, and resource implication of proposed changes can be made to decide on priori-
ty actions. These change ideas must be documented and tested using the principles of quality
improvement to identify which ones are actually linked to improvement. A detailed quality
im- provement plan on how the priority changes will be tested should be devised (P part of
PDSA). The quality improvement plan should include a detailed task for each prioritized
change ideas, assigned responsible persons, a reasonable time scale for completing the tasks
along with how and when progress will be measured (3). Once proposed changes are put in
place, their imple- mentation progress should be monitored regularly to ensure they are being
implemented as agreed plan and time frame (D part of PDSA). The responsible bodies that are
identified in the quality improvement plan will be accountable for the execution of the
changes in accord with the plan. The progress made in the implementation, the difficulties
faced and actions taken to address them should be studied, documented and reported in a
summarized form to the appro- priate body regularly (S part of PDSA). Developing or
identifying a small number of indicators to monitor the status of implementation and
improvements made would make the tracking ef- fective and help identify difficulties early.
The audit team will run multiple small scale PDSA cycles for each of the prioritized change
ideas and decides based on the findings of the cycles to adapt, adopt or abandon (A part of
PDSA).

Sustaining the improvement

The change ideas that have brought on the desired improvement will be incorporated
to the system. A new way of doing things is identified and these ways should be standardized
while removing the old methodologies. To make sure whether these changes have affected the
other parts of the clinical process, a second audit or re-audit will be conducted making the
pro- cess continuous. This cycle is repeated until the desired performance is achieved in the
overall clinical process for the specific topic.

Once the desired level of performance is achieved, targets can be revised (if set for
less than 100%), and the audit process will continue to meet the new targets, or the QIT can
devise audit standards and criteria that are more advanced or prioritize other audit topics,
develop stan- dards and criteria and continue with the process of clinical audit and
improvement.

It is important to note that documenting and disseminating successful audits is part of

sustaining improvement. The QI unit together with the QIT should document audits that have
brought on improvement and share it with all stakeholders. Using the existing learning plat-
forms, the knowledge obtained should be communicated to other departments and units within
and outside the institution (3).

23
7. Audit Monitoring Process
The recommended time to complete a clinical audit is three months, but this might depend
on the problems the audit team prioritized to address in one cycle. The audit team should assign an
estimated time of completion of the project at the beginning of the audit. The audit team should
notify the QI unit if a need for extension arises during the implementation of the clinical audit
project and this should be with sufficient justification(5).

Three phases along with an estimated period are identified to help track the status of the
audit and make the monitoring easy.

Phase 1- comprises team establishment, planning the delivery of audit, and data collection.
The estimated time is two weeks.

Phase 2- comprises data analysis and interpretation, problem prioritization, root cause analy-
sis, drawing a conclusion, developing change ideas, presentation of findings, and writing reports.
The estimated time is three weeks.

Phase 3- comprises designing and implementing QI projects, including testing change ideas
(PDSA) for each prioritized problem. The remaining period from the estimated date of completion
will be used for this phase. It is best to complete the phase-in seven weeks period.

Reaudit will be conducted at the end of the clinical audit project (ideally three months but
could be more depending on the length of QI project implementation).

Audit status indicator definition

 On track- project is progressing according to schedule
 Delayed- project is running but falls behind schedule
 Completed- each phase is completed according to the schedule
 Abandoned- the project is not completed within the initial estimated period or the exten-
sion period allowed.

24
8. Roles and responsibilities

MoH
● Oversee the implementation of clinical audit
● Update the guide regularly
● Build the capacity of regions
● Ensure coordination of the audit
● Evaluate clinical audit program (annual review meeting, periodic evaluation)
● Support the regions in the mobilization of resources
● Strengthen partnership
● Ensure the regions for allocation of resources for effective implementation of clinical
audit at all levels of health facility
● Plan, organize, and lead national clinical audit

Sub national (RHB, Zonal, district)

● Monitor the implementation of clinical audit
● Build the capacity of health facility
● Ensure coordination of the audit
● Evaluate clinical audit program (bi-annual review meeting)
● Mobilization and allocate budget for implementation of clinical audit
● Strengthen partnership

Health facility
● Establish audit teams/QIT
● Monitor the implementation of audits regularly
● Integrate clinical audit as a regular activity
● Ensure change is achieved as per the action plan
● Ensure capacity building of their respective staff
● Ensure availability of guidelines, protocols, and audit tools to service delivery unit

Healthcare Providers
● Involve actively in clinical audit
● Perform regular audit with the audit team
● Recording and documentation of audit
● Identify topics for clinical audit
● maintain client privacy and confidentiality

25
Quality Improvement team
● Plan for clinical audit
● Support the quality unit in the coordination of clinical audit
● Ensure the audit guideline is implemented
● Undertake analysis, interpretation of clinical audit
● Design the implementation of change as per the audit finding (support linkage of audit
activity with quality improvement activity)
● Ensure clinical audit is implemented by a multidisciplinary team
● Ensure presentation (dissemination) of clinical audit finding
● Monitor and evaluate the performance of clinical audit

Quality unit/directorate
● Support clinical audit team in planning clinical audit
● Support clinical audit team in the coordination of clinical audit and support for
overall quality improvement
● Makes approval of audit projects
● Register clinical audit projects and follow the execution as per the schedule
● Facilitate in the dissemination of audit findings using different platform
● Coordinate in analysis, interpretation of clinical audit
● support the implementation of change as per the audit finding (support linkage of
audit activity with quality improvement activity)
● Facilitate clinical audit to be implemented by a multidisciplinary team
● Support in monitoring and evaluating clinical audit performance

Partners
● Support (financially &/or technically) the implementation of clinical audit at all level

26
9. REFERENCES

1. Federal Ministry of Health. National Quality strategy 2016-2020.

2. NICE. Principles for Best Practice in Clinical Audit. Oxford, Radcliffe Medical Press, 2002.
3. Quality & Patient Safety Directorate Dr. Steevens Hospital Dublin (2013). A Practical Guide
to Clinical Audit.

4. Royal College of Nursing (1990) Quality Patient Care: The dynamic standard setting
system. Harrow: Scutari Press.

5. Lincolnshire Community Health Services NHS Trust. Clinical Audit Policy and Procedures
2018-2021.

27
28
Maternal Health Audit Tools
Audit Tool: ANC
Facility name
Department/unit
Audit Topic ANC

2
Aim To improve the quality of care for pregnant women
Objectives To ensure appropriate evaluation is made for pregnant women during ANC
To ensure appropriate investigations are made for pregnant women during ANC
To ensure appropriate care provided to all pregnant women
Period of Audit
Inclusion criteria All pregnant women having ANC follow up
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue) - if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient

Performance
Data Source

Remark
perfor-
verification

mance
No Standards/criteria Target

against
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Actual

target
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
and

1 DEMOGRAPHIC AND 100%

IDENTIFICA- TION INFORMATION
IS RECORD- ED FOR A
PREGNANT WOMAN DURING
ANC
1.1 Name
Integrate

1.2 Age
d ANC
chart

1.3 MRN
1.4 Address
2 APPROPRIATE HISTORY IS TAKEN 100%
USING INTEGRATED ANC CHART
FOR PREGNANT A WOMAN DUR-
ING ANC
2.1 Integrated ANC chart is used to take
Integrate

history
d ANC
chart

2.2 Gravidity/parity
2.3 Gestational age is calculated
2.4 Past obstetric history (previous mode
of delivery, Any pregnancy related

Integrated ANC chart

compli- cation) is taken
2.5 Present Pregnancy History (complaint)
is identified
2.6 Mental Health history is assessed
2.7 Medical history and Surgical
history is taken
2.8 Classifying form filled completely
2.9 Family/Social History is taken
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR
PREGNANT WOMAN DURING
ANC
3.1 General appearance (looked for facial
puffiness, expression of pain or worry,
and pallor)
3.2 Vital signs are measured
Blood pressure
Pulse rate
Temperature
RR
Integrated ANC

3.3 BMI is calculated

3.4 Mid upper arm circumference
chart

(MUAC) is measured
3.5 Conjunctiva is assessed for anemia
3.6 Breast is assessed for nipple retraction
3.7 Chest is auscultated
3.8 Precordium is auscultated
3.9 Fundal height (in wks.) is measured
3.10 Fetal heart beat (after 20 weeks)
is counted
3.11 Presentation after 34 weeks is deter-
mined

2
4 RELIVANT INVESTIGATIONS ARE 100%
DONE FOR A PREGNANT
WOMAN DURING ANC
4.1 Hemoglobin is determined at least at
ANC 1

Integrated ANC chart

4.2 Blood group and RH ( for unknown
ABO and RH status)
4.3 VDRL
4.4 HIV

3
4.5 HBsAg
4.6 Urine
4.7 Urine Gram stain
4.8 U/S done before 24weeks of gestation
5 APROPRIATE DIAGNOSIS IS MADE 100%
FOR A PREGNANT WOMAN DUR-
ING ANC
5.1 Trimester of pregnancy is mentioned on

Triangulate the history, P/E

and investigation findings
the diagnosis

on the Integrated ANC

5.2 Parity is mentioned on the diagnosis

chart
5.3 Pregnancy related complications are
mentioned in the diagnosis if present

6 PROPER COUNSELLING IS PRO- 100%

VIDED FOR A PREGNANT
WOMAN DURING ANC
6.1 Counselling on nutrition/healthy eating
is provided

6.2 Counselling on PMTCT is provided

Integrated ANC chart

6.3 Counselling on family planning

is provided
6.4 Counselling on breast feeding is
pro- vided
6.5 Counselling to avoid alcohol,
khat, smoking and other illicit
drugs is provided
6.6 Counselling on avoidance of
harmful traditional practices is
provided
6.7 Counselling on intimate partner vio-
lence is provided
6.8 Counselling on Birth Preparedness and
complication Readiness is provided
7 APPROPRIATE TREATMENT & 100%
VACCINES ARE PROVIDED FOR
A PREGNANT WOMAN
DURING ANC
7.1 Iron and folate is supplemented

Integrated ANC chart

7.2 Deworming medication is prescribed
7.3 Td vaccine is given
7.4 Maternal complication if present
are managed
7.5 Classified for basic or specialized care
7.6 Date Scheduled for the next contact
8 IDENTIFICATION OF PROVIDER IS 100%
DOCUMENTED FOR A PREGNANT
WOMAN DURING ANC
8.1 Name and Signature of the provider Integrat-
is clearly documented ed ANC
chart
Total standards met per chart
Percentage

References
National Antenatal Care Guideline 2021
National Obstetric Management protocol for Hospital 2021

3
Audit Tool: Labour and Delivery

Facility name
Department/unit Labour and delivery
Audit Topic labor and delivery

3
Aim To improve the quality of intrapartum care
Objectives To ensure laboring women coming for delivery are assessed appropriately
To ensure laboring women coming for delivery are followed appropriately
To ensure laboring women coming for delivery are managed with evidence based care
Period of Audit
Inclusion criteria All vaginal deliveries( spontaneous, induced, augmented, operative )
Exclusion criteria (where applicable) C/S deliveries
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Data Perfor-
Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Source mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target perfor- Remark
and verifi- against
mance
cation target
1 DEMOGRAPHIC AND IDENTIFICA- 100%
TION INFORMATION IS RECOREDED
FOR A LABORING WOMAN COMING
FOR DELIVERY
1.1 Name
History
1.2 Age sheet and
1.3 MRN Parto-
1.4 Address graph
2 APPROPRIATE HISTORY IS TAKEN AT 100%
ADMISSION FOR A LABORING WOM-
AN COMING FOR DELIVERY
2.1 Gravidity, parity are deermined
2.2 Gestational age is calculated
History
2.3 Past obstetric history is inquired sheet and
2.4 Duration of labor is sought Parto-
graph
2.5 Duration of Rupture of membrane is
determined
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
LABORING WOMAN COMING FOR
DELIVERY
3.1 General appearance is assessed
3.2 Vital signs are measured
Blood pressure
Pulse rate
Temperature
3.3 Conjunctiva is assessed for anemia
3.4 Chest is auscultated
3.5 Preicordium is auscultated
History
3.6 Obstetric abdominal palpation is per-
sheet
formed
3.7 Uterine contraction frequency and dura-
tion is determined
3.8 Fetal condition (fetal heart rate )
is assessed
3.9 Status of cervical dilatation is assessed
3.1 Fetal presentation is identified on
pelvic examination
4 LABOUR PROGRESS IS FOLLOWED 100%
WITH PARTOGRAPH FOR A LABOR-
ING WOMAN COMING FOR DELIV-
ERY
4.1 Partograph monitoring is used for active
stage of labour
4.2 Identification section is filled on
the partograph
Name
Parity
Parto-
Gravidity
graph
MRN
Date of admission

3
Time of admission
4.3 Fetal status is monitored
FHB is monitored at least every 30minutes
Status of liquor (Grading of meconium)
at least every 4hour
Molding (Grading of molding ) at
least every 4hour
4.4 Progress of labor is monitored

3
Uterine contraction at least every 30min-

Partogra
utes

ph
Descent of fetal head at least every 4hour
Cervical Dilatation at least every 4hour
4.5 Maternal well-being is monitored
Blood pressure measured
Pulse rate taken
Temperature taken
5 DECISION IS MADE BASED ON 100%
PARTHOGRAPH FINDING FOR A
LABORING WOMAN COMING FOR
DELIVERY
5.1 Decision is made based on parthograph

History/Prog-
Partograph/
finding

ress/order
sheet
6 LABORING WOMAN IS APPROPRI- 100%
ATELY FOLLOWED AT SECOND
STAGE OF LABOR FOR LABORING
WOMAN COMING FOR DELIVERY
6.1 Maternal conditions and wellbeing
is assessed
Blood pressure measured
Pulse rate taken
Temperature taken
6.2 Fetal well -being is monitored
FHB is monitored at least every 15 Parto-
min- utes graph
The status of liquor is evaluated
6.3 Progress of labor is evaluated
Descent and / or station every one hour
6.4 Delivery summary is properly document-
ed
7 THIRD STAGE OF LABOR IS MAN- 100%
AGED ACTIVELY FOR A LABORING
WOMAN COMING FOR DELIVERY
7.1 Uterotonics are given with in 1 minute of
delivery of the baby Parto-
graph/
7.2 Placenta is delivered with controlled
History/
cord traction
Progress
7.3 The tone of uterus is checked for one hour Sheet
after delivery
8 MOTHER WHO DELIVERED BY 100%
OPERATIVE VAGINAL DELIVERY/
ASSISTED INSTRUMENTAL DELIVERY
IS MANAGED APPROPRIATELY FOR
LABORING WOMAN COMING FOR
DELIVERY
8.1 Written informed consent is taken Consent
form
8.2 Date and time of procedure is written
8.3 Type of instrument used is specified
8.4 Type of application of instrument is
doc- umented
8.5 Indication is documented (prolonged Progress
second stage, NRFHRP, shorten second sheet/ par-
stage) tograph

8.6 Prerequisites are fulfilled and documented

8.7 Post procedure condition is documented
properly
8.8 Post procedure order is written and Order
attached sheet
9 APPROPRIATE DISCHARGE CARE IS 100%
PROVIDED FOR LABORING WOMAN
COMING FOR DELIVERY
9.1 Appropriate counseling is provided
Breast feeding
Danger signs for the mother and newborn

3
Safe sex Discharge
sheet
FP
9.2 Discharge summary is written
9.3 Status at discharge is documented
10 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR LABORING
WOMAN COMING FOR DELIVERY
10.1 Name and Signature of the provider Delivery
is clearly documented Summary
11 NEWBORN DELIVERED WITH APGAR 90%

3
SCORE OF 7 AND ABOVE
Total standards met per chart
Percentage

References
National Obstetric Management protocol
for Hospital 2021
Audit Tool: ENC
Facility
Department/unit
Audit Topic Essential Newborn Care
Aim To improve quality of clinical care provided for newborns in the delivery room
Objectives To ensure all live newborns born within the facility are appropriately evaluated
To ensure all live newborns delivered in the facility have received ENC
To ensure all live newborns with identified problems receive appropriate additional care
Period of Audit
Inclusion criteria All newborns delivered in the facility
Exclusion criteria (where applicable) Still birth, Newborns delivered in another facility and referred in
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Target Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria perfor- Remark
and verification against
mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR NEWNORN

1.1 Newborn has individual chart Newborn chart

1.2 Name (any identifying name)
1.3 Sex
1.4 Gestational age weeks
Newborn
1.5 Date of birth history sheet/
checklist
1.6 Time of birth
1.7 Age in hours
1.8 Mother’s name
2 APPROPRIATE EVALUATION IS 100%
PERFORMED FOR NEWBORN IM-
MEDIATELY AFTER BIRTH
2.1 Delivery summery is documented

3
Newborn histo-
2.2 Gender, gestational age, number ry sheet
of babies(singleton or multiple)
are identified
2.3 APGAR score (1st minute, 5th
minute and 10th minute) calculated or Newborn histo-
pres- ence of crying at birth is ry sheet
documented
2.4 Vital signs are taken with in 1 hour
Triangulate the
of life
time of birth

3
Respiratory rate with the time
Temperature vital signs are
taken on the
newborn histo-
Heart rate
ry sheet

2.5 Anthropometric measurements are

taken

Weight
length
Head circumference
Newborn histo-
ry sheet
2.6 Maternal hepatitis B status is identified

2.8 Maternal blood group and Rh is iden-

tified
2.9 Maternal status of syphilis and HIV
are identified
2.7 Cord blood is collected for blood group Triangulate the
and Rh determination when mother’s maternal RH
blood group is O and / or Rh negative result with the
lab investiga-
tion paper in
the neonatal
chart
3 OPTIMAL ESSENTIAL NEWBORN 100%
CARE IS PROVIDED FOR A NEW-
BORN IMMEDIATELY AND WITH-
IN FEW HOURS AFTER BIRTH
3.1 For newborn who didn’t breath/cry at Triangulate
birth neonatal resuscitation is done the apgar
score with the
management
provided on
the Newborn
history sheet
3.2 Baby delivered on mothers
abdomen and dried immediately
after birth
3.3 Skin to skin is done Newborn histo-
ry sheet
3.4 Delayed cord clamping is done
(time for cord cut at least 1 minute
docu- mented )
3.5 Breast feeding is initiated with in 1 Triangulate the
hour of life time of birth
with the time
breast feeding
is initiated on
the Newborn
history sheet
3.6 Vitamin K is given according to na-
tional guidelines
Newborn histo-
ry sheet
3.7 Eye prophylaxis is given with TTC

3.8 If maternal blood group is RH negative Triangulate the

,indirect coombs test result of the maternal RH
mother is documented and anti D is result with the
given lab investiga-
tion request in
the neonatal
chart with
the treatment
provided on
the newborn
history sheet
3.9 If the maternal indirect coombs test is Triangulate
positive newborn is referred to NICU the lab result
for indirect
coombs test on
the Newborn
history sheet
with the in-

3
ternal referral
paper/delivery
log book
3.10 If newborn is exposed to maternal Triangulate
syphilis, newborn transferred to NICU the maternal
for management syphilis status
on the New-
born history
sheet with the
internal referral

4
paper/delivery
logbook
3.11 For infant exposed to HIV Triangulate the
prophylaxis with AZT and Nevirapin maternal HIV
is initiated with in 12 hours status with the
management
provided on
the Newborn
history sheet
3.12 Vaccination is provided or appointment
is given for vaccination if discharged
with out vaccination Newborn histo-
ry sheet
3.13 Mother is advised breastfeeding
before discharge
4 APROPRIATE ADDITIONAL 100%
MANAGEMENT IS PROVIDED FOR
NEWBORN WITH IDENTIFIED
PROBLEMS
4.1 Newborn weighing < 2000 gram and
more than 1500 gram and clinically
stable is kept in the post natal ward
for 72 hours Newborn histo-
4.2 Newborn weighing < 2000 gram ry sheet
and more than 1500 gram is
initiated on kangaroo mother care

4.3 For newborn weighing less than 2000 Newborn

gram or more than 1500 grams history sheet/
feeding is secured before discharge discharge
summary on
maternal chart
4.4 Newborn weighing less than 1500 Triangulate the
gram is admitted to NICU weight on the
Newborn his-
tory sheet with
internal referral
paper/delivery
log book
4.5 Newborn with danger signs on vital Triangulate the
signs or physical exam is transferred vital signs on
to NICU the Newborn
history sheet
with internal
referral paper/
delivery log
book
5 NEWBORN’S BODY TEMPERATURE 100%
RANGE BETWEEN 36.5–37.5 °C AT
THE FIRST HOUR AFTER BIRTH
Total standards met per chart
Percentage

References:
Essential Care for Every Baby Training
Manual 2016

4
Audit Tool: Postnatal
Facility name
Department/unit
Audit Topic Immediate Postnatal care

4
Aim To improve the quality of care during immediate Postpartum/Postnatal period
Objectives To ensure appropriate evaluation is done for the mother and newborn during immediate postnatal period
To ensure appropriate counselling is provided for the mother during immediate postpartum period
Period of Audit
Inclusion Criteria All women who delivered in Hospitals with in 24 hrs.
Exclusion criteria (where applicable) Women who gave birth at home admitted to hospitals with postpartum complications
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient

No Standards/criteria Target Data Actual Perfor- Remark

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Source per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
and veri- for- against
fication mance target
1 DEMOGRAPHIC AND IDENTIFICA- 100%
TION INFORMATION IS RECORED-
ED DURING IMMEDIATE POSTPAR-
TUM PERIOD
1.1 Name
Progress
1.2 Age note and
1.3 MRN Parto-
1.4 Address graph
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A MOTHER AND NEWBORN
DURING IMMEDIATE POSTPARTUM
PERIOD
2.1 Parity of the mother is identified
2.2 Mode of delivery is identified
Progress
2.3 Presence of bleeding is assessed note /Par-
2.4 Breast feeding initiation status is assessed tograph
2.5 Level of pain is assessed
3 APPROPRIATE MONITORING OF 100%
MATERNAL CONDITION IS DONE
DURING IMMEDIATE POSTPARTUM
PERIOD
3.1 Vital Signs are monitored every 15 min
with in the first 2 hours: then 4hrly if it Triangu-
is normal late order
Blood pressure sheet with
Vital sign
Pulse rate sheet
Temperature
3.2 Conjunctiva is assessed for pallor
every 4 hours
3.3 Uterine tone is assessed every 15’ for
one hour after delivery
Progress
3.4 Presence of Vaginal bleeding is asessed
note
every 15’ for one hour after delivery
3.5 Perineum is inspected for any
problem, (episiotomy, laceration)
every 15 min with in the first one
hour: then 4hrly
4 APPROPRIATE CARE/TREATMENT IS 100%
PROVIDED FOR A MOTHER
DURING IMMEDIATE POSTNATAL
PERIOD
4.1 Iron for 3 months is provided Order
4.2 Immediate PPFP is provided sheet
5 APPROPRIAT COUNSELING IS 100%
PROVIDED FOR A MOTHER
DURING IMMEDIATE POSTPARTUM
PERIOD
5.1 Counseling on breast feeding is provided
5.2 Counseling on danger signs of the moth-
Parto-
er and newborn is provided
graph/
5.3 Counselling on nutrition is provided Progress
5.4 Counselling on postpartum care and sheet/
hygiene is provided Delivery
summary

4
5.5 Counselling on return follow up visit
is provided
6 APPROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A MOTHER AND
NEWBORN DURING IMMEDIATE
POSTNATAL PERIOD
6.1 Appropriate counseling is provided
Breast feeding
Danger signs for the mother and new-
born
Safe sex
Discharge

4
FP sheet
Nutrition
Hygiene
6.2 Iron/folate is given for 3 month’s
6.3 Next appointment is given
7 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A
MOTHER
DURING IMMEDIATE POSTPARTUM
PERIOD
7.1 Name and Signature of the physician is
clearly documented on all admission and History
history and physical examination (P/E) sheet
sheet during immediate postnatal period
7.2 Name and Signature of the physician is
Progress
clearly documented on all progress
sheet
note during immediate postnatal
period
7.3 Name and Signature of the physician
Order
is clearly documented on all order
sheet
sheet during immediate postnatal
period
7.4 Name and Signature of the nurses is
Medica-
clearly documented on all medication
tion sheet
sheet during immediate postnatal period
7.5 Name and Signature of the
Parto-
providers clearly documented on
graph
partograph during immediate
postnatal period
Total standards met per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021
Audit Tools: PPH

Facility name
Department/unit
Audit Topic PPH Management
Aim To improve the quality of care for PPH management
Objectives To ensure appropriate evaluation is done for all women who developed PPH
To ensure women who developed PPH are managed appropriately
Period of Audit
Inclusion criteria Mothers who developed PPH within 24 hrs. of delivery
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient

Remark

Performance
Data Source

formance
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
No Standards/criteria Target and verifica-

against
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9

Actual

target
tion

per-
1 DEMOGRAPHIC AND IDENTIFICA- 100%
TION INFORMATION IS RECOREDED
FOR A WOMAN WHO DEVELOPED
PPH
1.1 Name
1.2 Age History
1.3 MRN sheet
1.4 Address
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A WOMAN WHO
DEVELOPED PPH
2.1 Obstetrics history including time of
deliv- ery and onset of bleeding is
obtained
History
2.2 Risk factors are assessed

4
sheet
2.3 Personal and family history of
bleeding tendency is asessed
2.4 Medications history is inquired
3 APPROPRIATE PHYSICAL EXAMINA- 100%
TIONS IS PERFORMED FOR A WOM-
AN WHO DEVELOPED PPH
3.1 General Appearance is assessed
3.2 Vital sign are measured
BP History

4
sheet/Vital
PR
sign sheet
Temp
Oxygen saturation(SPO2)
3.3 Conjunctiva is assessed for pallor
3.4 Size and tone of the uterus is assessed
3.5 Exploration for genital tract trauma is done
(Vagina and cervix are assessed for tear, History
laceration, hematoma, uterus is checked sheet
for rupture)
3.6 Mental status is assessed (Level of
con- sciousness)
4 APROPRIATE DIAGNOSIS IS MADE 100%
FOR A WOMAN WHO
DEVELOPED PPH
4.1 Cause of the PPH is identified Ttriangulate
the history
and P/E
4.2 Estimated blood loss is determined findings
with the
diagnosis on
4.3 Presence of shock is identified the history
sheet
5 APPROPRIATE TREATMENT AND 100%
CARE IS PROVIDED FOR A WOMAN
WHO DEVELOPED PPH
5.1 Two IV line is secured and
crystalloid infusion started
Triangulate
5.2 Blood for hematocrit and cross-match is progress
taken note with
5.3 Oxygen by face mask is given order sheet
5.4 The patient is positioned flat with medi-
cation sheet
5.5 Uterine massage is performed every 15’
for 2hrs
5.6 Uterotonic agent is administered according
to the protocol
Triangulate
5.7 Tranexamic acid (TXA) is progress
administered within 3 hrs. of birth note with
5.8 NASG is applied order sheet
5.9 Uterine balloon tamponade (UBT) is with medi-
inserted cation sheet
5.10 Blood is transfused when indicated
6 APPROPRIATE MONITORING OF 100%
MA- TERNAL CONDITION IS DONE
FOR A WOMAN WHO DEVELOPED
PPH
6.1 Vital signs are monitored appropriately

Triangulate
BP is measured every 15’ for 2 hrs. order sheet
PR is taken every 15’ for 2 hrs. with vital
Temp taken every 15’ for 2 hrs. sign sheet
O2 saturation is measured
6.2 Bladder is catheterized and urine output
monitored at least for 2 hrs.
6.3 Mother is monitored for bleeding Progress
sheet
6.4 Surgical management is made for
bleeding if the above management fails
7 APPROPRIATE DISCHARGE CARE IS 100%
PROVIDED FOR A WOMAN WHO
DEVELOPED PPH
7.1 Counseling is provide
Danger signs
Family planning Discharge
summary
Nutrition
sheet
7.2 Iron/folate is given for 3 months
7.3 Next appointment is given
8 IDENTIFICATION OF PROVIDER IS 100%
DOCUMENTED FOR A WOMAN
WHO DEVELOPED PPH

4
8.1 Name and Signature of the physician is
clearly documented on all admission and History
history and physical examination (P/E) sheet
sheet
8.2 Name and Signature of the physician is Progress
clearly documented on all progress note sheet

4
8.3 Name and Signature of the physician
Order sheet
is clearly documented on all order
sheet
8.4 Name and Signature of the nurses is Medication
clearly documented on all medication sheet
sheet
9 A WOMAN WHO DEVELOPED 100%
PPH SURVIVED FROM PPH
Total standards per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021
Audit Tool: Sepsis
Facility name
Department/unit
Audit Topic Mother with Sepsis
Aim To improve the quality of clinical care provided for women with sepsis
Objectives To ensure appropriate evaluation is made for women with sepsis
To ensure relevant investigations are done for women with sepsis
To ensure appropriate treatment and care is provided for women with sepsis
Period of Audit
Inclusion criteria All women with sepsis after 24 of delivery
Exclusion criteria (where applicable) Women having sepsis after 10 days of delivery
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient

Perfor-
Data Source Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION IS 100%
RECOREDED FOR A WOMAN
WITH SEPSIS
1.1 Name
1.2 Age
History sheet
1.3 MRN
1.4 Date of evaluation
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A WOMAN WITH SEPSIS
2.1 Parity of the mother is identified
2.3 Mode of delivery and outcome is
deter- mined
2.4 Presence of fever is asked and
charac- terized
History sheet
2.5 Presence of cough is asked and

4
charac- terized
2.6 Presence of bilateral pain and
swelling in the breast are asked and
character- ized
2.7 Presence of offensive Lochia is inquired
2.8 Presence of lower abdominal pain
is asked and characterized
2.9 Presence of urinary frequency and History sheet
urgency are asked
2.10 Presence of flank pain is asked

5
and characterized
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
WOMAN WITH SEPSIS
3.1 Vital signs are measured
BP
History
PR sheet/Vital
RR sign sheet
Temperature
3.2 Breast is evaluated for signs of infection
(inspection and palpation)
3.3 Chest is auscultated
3.4 Wound site is evaluated for signs
of infection (inspected and
palpated )
3.5 Abdomen is palpated for tenderness History sheet
3.6 Uterus is examined for size and
tender- ness
3.7 Genito urinary system is examined for
CVA and supra pubic tenderness
3.8 Episiotomy site is thoroughly
examined (inspection and palpation)
4 RELEVANT INVESTIGATIONS ARE 100%
PERFORMED FOR A WOMAN
WITH SEPSIS
4.1 CBC Triangulate
History
4.2 Urine analysis sheet/order
4.3 U/S sheet with
investigation
4.4 LFT and RFT papers
5 APPROPRIATE TREATMENT AND 100%
CARE IS PROVIDED FOR A WOMAN
WITH SEPSIS
5.1 IV is opened Triangulate
5.2 Guideline concordant antibiotics are Order sheet
started with Medica-
tion sheet
5.3 Evacuation of tissues are done in Triangulate
moth- er with RPC order sheet
with proce-
dure note
5.4 Complications are identified and Triangulate
managed history,P/E
and Ix
findings with
order sheet
6 APPROPRIATE MONITORING IS 100%
DONE FOR A WOMAN WITH
SEPSIS
6.1 Vital signs are measured every 4 hourly
BP Triangulate
RR order sheet
with vital
Temperature sign sheet
Pulse Rate
7 APPROPRIATE DISCHARGE CARE IS 100%
PROVIDED FOR A WOMAN WITH
SEPSIS
7.1 Counselling is provide
Danger signs
Family planning Discharge
Safe sex sheet
Nutrition
Hygiene
8 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A
WOMAN WITH SEPSIS

5
8.1 Name and Signature of the physician
is clearly documented on all
History sheet
admission and history and physical
examination (P/E) sheet
8.2 Name and Signature of the physician is Progress
clearly documented on all progress note sheet

5
8.3 Name and Signature of the physician
Order sheet
is clearly documented on all order
sheet
8.4 Name and Signature of the nurses is
Medication
clearly documented on all medication
sheet
sheet
9 A WOMAN ADMITTED WITH 90%
SEP- SIS IMPROVED AND
DISCHARGE
Total standards met per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021
Audit Tool: Pre-eclampsia
Facility name
Department/unit
Audit Topic Mothers admitted with Preeclampsia
Aim To improve the quality of care provided to mothers who are admitted with Pre-eclampsia
Objectives To ensure mothers who are admitted with pre-eclampsia are evaluated appropriately
To ensure mothers who are admitted with pre-eclampsia are appropriately diagnosed
To ensure mothers who are admitted with pre-eclampsia received evidence based management
Period of Audit
Inclusion criteria All women admitted with the diagnosis of pre-eclampsia, eclampsia and supper imposed pre-eclampsia.
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient

Perfor-
Data Source Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Tar- mance

chart 1

chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria and verifica- perfor- Remark
get against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A MOTHER
ADMITTED WITH PREECLAMPSIA
1.1 Name
1.2 Age
History sheet
1.3 MRN
1.4 Date of evaluation
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A MOTHER ADMITTED
WITH PREECLAMPSIA
2.1 Presence of headache is asked
and characterized
2.2 Presence of blurring of vision is asked
2.3 Presence of epigastric pain is
asked and characterized

5
History sheet
2.4 Presence of shortness of breath
is asked and characterized
2.5 Presence of history of loss of con-
sciousness is asked and
characterized
3 APPROPRIATE PHYSICAL EX- 100%
AMINATION IS PERFORMED FOR
A MOTHER ADMITTED WITH
PREECLAMPSIA
3.1 Vital signs are measured
BP

5
PR
RR
Temprature
3.2 Conjunctiva is assessed for pallor
3.3 Chest is auscultated History sheet
3.4 Precordium is auscultated
3.5 Obstetrics palpation is performed
3.6 FHB is checked
3.7 Deep tendon reflex are assessed
3.8 Level of consciousness is assessed
4 RELEVANT INVESTIGATIONS ARE 100%
DONE FOR A MOTHER ADMIT-
TED WITH PREECLAMPSIA
4.1 CBC every other day History
4.2 Liver enzymes and creatinine sheet and
twice weekly investigation
4.3 Fetal biophysical profile twice weekly request
5 APPROPRIATE TREATMENT AND 100%
CARE ARE PROVIDED AT ADMIS-
SION FOR A MOTHER ADMITTED
WITH PREECLAMPSIA
5.1 IV Antihypertensive is given When
BP measurement >160/110mmHg
5.2 IV Antihypertensive is given When
BP measurement >160/110mmHg Triangulate
order sheet
5.3 MgSo4 Loading and maintenance
with medica-
dose is given for at least 24hrs
tion sheet
after admission
5.4 Dexamethasone 6mg IM given for
48 hours for GA < 37 wks. is given
6 APPROPRIATE MONITORING IS 100%
DONE AT ADMISSION FOR THE
MOTHER ADMITTED WITH
PREECLAMPSIA
6.1 Vital signs are measured every 20’
then every 4hrly after stabilization
Triangulate
BP order sheet
PR. with vital
Temperature sheet
RR
6.2 MgSo4 toxicity monitoring sheet Triangulate
is filled and attached Order sheet
6.3 FHB is monitored at least once daily with moni-
6.4 Urine output is monitored daily toring sheet
7 WOMAN WITH PRE-ECLAM- 100%
SIA IS RECEIVED APPROPRIATE
TREATMENT AND CARE DURING
LABOUR AND DELIVERY FOR
A MOTHER ADMITTED
WITH PREECLAMPSIA
7.1 IV Antihypertensive is given When Triangulate
BP measurement ≥160/110mmHg order sheet
with medica-
tion sheet
7.2 FHR is monitored every 15 minutes
during active stage and every 5 Triangulate
min- utes in the 2nd stage Order sheet
7.3 Maternal conditions are monitored with Labour
using partograph Monitoring
7.4 Labour progress is monitored using sheet
partograph
7.5 Maintenance dose of MgSo4 is contin-
Order sheet
ued for 24 hours
7.6 MgSo4 toxicity monitoring sheet Triangulate
is filled and attached Order sheet
with Labour

5
Monitoring
sheet
8 APPROPRIATE MONITORING IS 100%
DONE DURING POST PARTUM
PE- RIOD FOR A MOTHER
ADMITTED WITH
PREECLAMPSIA
8.1 Vital signs are monitored for the first
2hrs every 15 minutes and then
every 4hrs Triangulate
BP measured order sheet
PR. taken with Vital
sign sheet

5
Temp. taken
RR taken
8.2 UOP is monitored Triangulate
Order sheet
with moni-
toring sheet
8.3 Liver and renal function tests Triangu-
are checked late order/
progress
sheet with
investigation
papers
8.4 Daily progress evaluation is done until Progress
discharge sheet
8.5 IV Antihypertensive is given
When BP measurement Triangulate
>160/110mmHg order sheet
8.6 Maintenance dose of MgSo4 is contin- with medica-
ued for the first 24 hrs. tion sheet
8.7 MgSo4 toxicity is monitored
9 ADDITIONAL TREATMENT IS 100%
PROVIDED FOR A MOTHER
WITH ECLAMSIA
9.1 Patient is positioned on left lateral
/ head down
9.2 Airway is opened and secured Order sheet/
History sheet
9.3 Oxygen is given
9.4 Catheter is inserted
9.5 IV antibiotics are administered Triangulate
order sheet/
history sheet
with medica-
tion sheet
9.6 Delivery is planned with in 12 hours Order sheet/
History sheet
10 APPROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A MOTHER AD-
MITTED WITH PREECLAMPSIA
10.1 Appropriate counseling is provided
Breast feeding
Danger signs for the mother and
newborn
Safe sex Discharge
FP sheet
Nutrition
10.2 Anti-hypertensive therapy is given
10.3 Follow-up appointment is given
11 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A
MOTH- ER ADMITTED WITH
PREEC- LAMPSIA
11.1 Name and Signature of the physician
is clearly documented on all
History sheet
admission and history and physical
examination (P/E) sheet
11.2 Name and Signature of the
Progress
physician is clearly documented on
sheet
all progress note
11.3 Name and Signature of the physician
Order sheet
is clearly documented on all order
sheet
11.4 Name and Signature of the nurses is
Medication
clearly documented on all medication
sheet
sheet
12 NEWBORN DELIVERED WITH 85%
APGAR SCORE OF 7 AND ABOVE
13 A MOTHER ADMITTED WITH 100%
PREECLAMPSIA IS DISCHARGED
WITH DIASTOLIC BLOOD PRES-
SURE <110 MMHG
Total standards met per chart

5
Percentage

References
National obstetric Management protocol for Hospital 2021
Audit Tool: CS
Facility name
Department/unit
Audit Topic Cesarean section
Aim To improve the quality of care provided for women who delivered by CS

5
Objectives To ensure women who gave birth by CS are evaluated appropriately
To ensure women had undergone CS received evidence based intraoperative care
To ensure women who gave birth by CS received evidence based post operative care
Period of Audit
Inclusion criteria All women who gave birth by elective CS
Exclusion criteria (where applicable) Women who delivered by emergency CS
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individ- ual patient

Perfor-
Data Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance

chart 1

chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Source and perfor- Remark
against
verification mance
target
1 ADEQUATE PRE-OPERATIVE 100%
PREPARATION IS MADE FOR
A MOTHER WHO DELIVERED
BY CS
1.1 Informed consent is taken
Name of the patient or the guardian
Description of procedure
Type of anesthesia Consent
form
Operating surgeon name
Patient or guardian signature
Two witnesses’ name and signature
1.2 Decision note is written
Date and time of decision Follow up
sheet/par-
Indication
tograph
Name and signature
1.3 Antibiotics are given 30 min Triangu-
before surgery late order
sheet with
medication
sheet
1.4 Hgb/Hct update, blood group, and Triangulate
RH are determined order sheet
with in-
vestigation
paper
2 STANDARD INTRAOPERATIVE 100%
CARE IS PROVIDED DURING
CEASARIAN SECTION FOR A
MOTHER WHO DELIVERED BY
CS
2.1 Maternal vital signs are taken
before anesthesia is administered
BP
Anesthesia
PR sheet
RR
O2 saturation (SPO2)
2.2 Intra operative patient safety is
maintained using WHO surgical
safety checklist (all fields are com-
pleted) Safe
surgery
Sign in checklist
Time out
Sign out
2.3 Anesthesia follow up sheet is
com- pleted and attached Anesthesia
sheet
2.4 Time of incision is documented
2.5 Description of procedure properly is
documented
Type of skin incision
Intra operative findings Operation
Note/Anes-
What was done

5
thesia sheet
Instrument and gauze count
2.6 Oxytocin is administered after
delivery
3 POST OPERATIVE CARE TO BE 100%
CARRIED OUT IN THE POST
ANESTHESIA CARE UNIT AND
WARD CLEALRY COMMUNI-
CATED FOR A MOTHER WHO
DELIVERED BY CS

6
3.1 Post operative order is written and
Order sheet
attached
Post-operative follow up of V/S
are measured every 15min for the
first 02hrs
BP
PR
RR
Triangulate
O2 saturation
order sheet
3.2 Post-operative follow up of V/S are with Vital
measured every 04hrly for the rest sign sheet
of her stay in the hospital
BP
PR
RR
O2 saturation
3.3 Order sheets are revised daily Order sheet
3.4 Progress of the patient is Progress
followed daily till discharge note
3.5 Pain score is filled for every Vital sign
mother and managed if the score is sheet
>3
4 APPROPRIATE DISCHARGE 100%
CARE IS PROVIDED FOR A
MOTHER WHO DELIVERED BY
CS
4.1 Proper counseling is provided
Breast feeding
Danger signs for the mother and
newborn Discharge
sheet
Safe sex
Family planning
Nutrition
Hygiene
Wound care
4.2 Iron/folate is given for 3 month’s
Discharge
4.3 Next appointment is provide sheet
4.4 Presence of Swollen, red, painful
area in the leg are assessed
before discharge
5 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A
MOTH- ER WHO DELIVERED BY
CS
5.1 Name and Signature of the physi-
cian is clearly documented on all History
admission and history and physical sheet
examination (P/E) sheet
5.2 Name and Signature of the
Progress
physi- cian is clearly
sheet
documented on all progress note
5.3 Name and Signature of the
physician is clearly documented on Order sheet
all order sheet
5.4 Name and Signature of the nurses
Medication
is clearly documented on all
sheet
medica- tion sheet
6 NEWBORN DELIVERED WITH 90%
APGAR SCORE OF 7 AND ABOVE
7 WOMAN WHO DELIVERED BY 100%
ELECTIVE CS DISCHARGED
WITH OUT COMPLICATION
Total standards met per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021

6
Audit Tool: CAC
Facility name
Department/unit
Audit Topic Comprehensive abortion care
Aim To improve the quality of CAC service

6
Objectives To ensure women coming for CAC are evaluated appropriately
To ensure women coming for CAC are managed appropriately
Period of Audit
Inclusion criteria All women with gestational age is ≤24 weeks came for CAC service
Exclusion criteria (where applicable) All pregnant women whose gestational age is > 24 weeks
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient

Data Perfor-
Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Tar- Source mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria perfor- Remark
get and verifi- against
mance
cation target
1 DEMOGRAPHIC AND IDENTIFICA- 100%
TION INFORMATION IS RECORDED
FOR A WOMAN WHO CAME FOR
CAC SERVICE
1.1 Name
1.2 Age History
1.3 MRN sheet
1.4 Address
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A WOMAN WHO CAME FOR
CAC SERVICE
2.1 Chief complaint is identified
2.2 Gestational age is calculated
2.3 Major medical problems is inquired
2.4 Past surgical history is inquired History
sheet
2.5 Past obstetric history is taken
2.6 Current medications and allergies are
asked
3 APPROPRIATE PHYSICAL EXAMINA- 100%
TION IS PERFORMED FOR WOMAN
CAME FOR CAC SERVICE
3.1 Vital signs are taken
BP
PR
Temp History
3.2 Abdominal examination is done to Sheet
assess fundal height
3.3 Pelvic / bimanual examination is done
3.4 Ultrasound is performed if available
4 RELEVEANT INVESTIGATIONS ARE 100%
DONE FOR A WOMAN WHO
CAME FOR CAC SERVICE
4.1 Hematocrit/hemoglobin Investi-
gation/
4.2 Blood group and Rh History
sheet
5 APPROPRIATE MANAGEMENT IS 100%
PROVIDED FOR A WOMAN
WHO CAME FOR CAC SERVICE
5.1 Written informed consent is taken Consent
sheet
5.2 Manual vacuum aspiration procedure is Procedure
performed appropriately note
Pain medication is given Triangu-
Doxycycline/Azithromycin/Metronida- late order
zole is given before the procedure sheet with
medica-
tion sheet
Completeness of the procedure is
con- firmed
Bimanual examination is performed Procedure
note
The product of conception up on comple-
tion of the procedure is evaluated

6
5.3 For ≤ 12 weeks of gestational age Medical
abortion drug regimen is administered
appropriately
Mefipristone 200 mg PO given
Misoprostol 800 μg buccal/vaginal
/ sublingual is given 24 - 48 hrs.

6
after mefipristone
Pain medication is given
Triangu-
5.4 For 13-24 weeks of gestational age Med- late order
ical abortion drug regimen is adminis- with med-
tered appropriately ication
Mefipristone 200 mg PO is given sheet
Misoprostol 400 μg buccal or vaginal
or sublingual is given 24 - 48 hrs.
after mefipristone
Misoprostol 400 μg buccal or vaginal
or sublingual is given every 3 hourly
until expulsion
5.5 Pain medication is given
6 APPROOPRIATE MONITORING 100%
OF MATERNAL CONDITION IS
DONE FOR A WOMAN WHO
CAME FOR CAC SERVICE
6.1 Vital signs are monitored
Triangu-
BP late order
PR sheet with
Temprature vital sign
sheet
Pain scoring
7 APPROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A WOMAN
WHO CAME FOR CAC SERVICE
7.1 Instructions or advise on danger sign is
provided
Excessive bleeding
Fever Discharge
Severe abdominal pain/cramp summary
sheet
Foul smelling /unusual vagina discharge
7.2 FP Counseling is provided
7.3 FP Service is provided
8 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A
WOMAN WHO CAME FOR CAC
SERVICE
8.1 Name and Signature of the physician is
clearly documented on all admission and History
history and physical examination (P/E) sheet
sheet
8.2 Name and Signature of the physician Order
is clearly documented on all order sheet
sheet
Total standards met per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021

6
Audit Tool: FP
Facility name
Department/unit
Audit Topic Family planning
Aim To improve the quality of family planning services

6
Objectives To ensure appropriate evaluation is performed for family planning clients
To ensure evidence based family planning counselling is provided for family planning clients
To ensure appropriate family planning family planning service is provided for family planning clients
Period of Audit
Inclusion criteria All women and girls who came for family planning counselling and service
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individ- ual patient

perfor- mance
Data Source
Target

Performance
No Standards/criteria and verifica- Remark

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
tion

against
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9

Actual

target
1 DEMOGRAPHIC AND IDEN- 100%
TIFICATION INFORMATION
IS RECORDED FOR A CLIENT
COMING FOR FAMILY PLANNING
SERVICES
1.1 Name
1.2 Age
1.3 MRN Client chart
/FP chart
1.4 Address
1.5 Date of visit
2 APPROPRIATE HISTORY IS TAK- 100%
EN FOR A CLIENT COMING
FOR FAMILY PLANNING
SERVICES
2.1 Past obstetric history ( parity )
is inquired
2.2 Presence of chronic diseases
(HPN, DM,CVS) are assessed
2.3 Last Menstrual Period (LMP) Client chart
is identified /FP chart
2.4 History of medications is asked
2.5 Breast feeding status is identified
2.6 History of Pelvic infection is inquired
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR
A CLIENT COMING FOR FAMILY
PLANNING SERVICES
3.1 Blood pressure is measured
3.2 Weight and Height are measured
3.3 Breast is inspected and palpated
Client chart
3.4 Precordium is auscultated
/FP chart
3.5 For IUCD insertion, bimanual
palpation is done to determine size,
position and signs of infection
4 APPROPRIATE INFORMATION 100%
AND COUNSELING IS PROVIDED
USING REDI COUNSELLING AP-
POACH FOR A CLIENT COMING
FOR FAMILY PLANNING SERVIC-
ES
4.1 Information on all methods is pro-
vided REDI coun-
selling
4.2 Counselling is documented
4.3 Client medical eligibility is confirmed Eligibility
chart
4.4 Outcome of counselling is docu- REDI coun-
mented selling
4.5 Informed consent is obtained Consent
form

6
4.7 Client is informed about warning
signs Client chart
/FP chart
4.8 Follow up visit is scheduled
7 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A CLIENT
COMING FOR FAMILY PLANNING
SERVICES
7.1 Name and Signature of the provider
is clearly documented on all Client chart

6
admission and history and physical /FP chart
examination (P/E) sheet
5 A CLIENT COMING FOR FAMILY 100%
PLANNING SERVICES IS PROVID-
ED WITH THE CHOSEN
METHOD OF FAMILY PLANNING
METHOD
Total standards met per chart
Percentage

References
National Obstetric Management protocol for Hospital 2021
Neonatal and Child Health Audit Tools
Audit Tool: Preterm Care
Facility name
Department/unit
Audit Topic Preterm care/LBW
Aim To improve the quality of clinical care provided for newborns delivered before 37 weeks of gestational age and/ or birth
weight less than 2500 gram (admitted to NICU)
Objectives To ensure neonates born before 37 weeks of gestational age and /or birth weight less than 2500 grams are appropriately
evaluated
To ensure neonates born before 37 weeks of gestational age and /or birth weight less than 2500 grams are appropriately
investigated
To ensure neonates born before 37 weeks of gestational age and /or birth weight less than 2500 grams are appropriately
treated
To ensure neonates born before 37 weeks of gestational age and /or birth weight less than 2500 grams are appropriately
monitored
To ensure neonates born before 37 weeks of gestational age and /or birth weight less than 2500 grams receive
appropriate discharge care
Period of Audit
Inclusion criteria All newborns admitted to NICU with birth weight less than 2000 gram and/or gestational age less than 37 weeks
Exclusion criteria (where applicable) Newborns who are observed and returned back to mother with in 24 hours of life, newborns who died on arrival to
NICU
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
For the monitoring section, use data from the first seven days of patient’s admission
Perfor-
Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source and mance
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target perfor- Remark
verification against
mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
PRETERM NEONATE
1.1 Name/identification
1.2 Age of the newborn at admission

6
1.3 Gender of the newborn NICU admission
history sheet
1.4 Date and time of birth
1.5 Birth weight
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A PRETERM NE-
ONATE
2.1 Place of delivery is identified
(in the facility, referred from
other facility or home )

7
2.2 Gestational age is determined
based on LMP/obstetrics US
2.3 Maternal age, parity, marital
status, occupation, address is
inquired
2.4 The history of antenatal care follow
up is assessed (Whether the mother
had ANC visits, number of visits,
ANC services she obtained and
their results - blood group and RH,
VDRL, HIV, HBSAG,TT vaccines)
2.6 Drugs the mother took/is taking NICU admission
are identified-dexamethasone, history sheet
magnesium sulphate, antibiotics..
2.7 The presence of possible risk
factors for preterm birth is as-
sessed-(hypertension, PROM,
Un- known, multiple gestation,
APH, maternal infection,pyuria)
2.8 The circumstances around the la-
bor are inquired (onset of labor(in-
duced or spontaneous, duration of
labor and mode of delivery)
2.9 Whether there were newborn inter-
vention made in the delivery room
is determined -need for resuscita-
tion, use of delivery room CPAP
for newborns less than 32 weeks,
3 APPROPRIATE PHYSICAL 100%
EXAMINATION IS PERFORMED
FOR A PRETERM NEONATE
3.1 Vital sign are taken
NICU admission
HR (Heart Rate) history sheet
RR and vital sign
BP sheet
Temperature NICU admission
history sheet
SpO2 (oxygen saturation) and vital sign
sheet
3.2 Anthropometric measurements are
taken and interpreted for GA
Weight for GA
Head circumference GA
Length GA
3.3 Signs of birth injury are assessed(-
subgaleal hemorrhage, cephal
hematoma, )
3.4 Respiratory system is examined for
cyanosis, retractions, chest in
draw- ing, apnea, tachypnea,
crepitation, and status of air entry
3.5 CVS is examined for pulse
rhythm and volume, capillary
refill time and murmurs
NICU admission
3.6 Abdomen is examined for - bleed- history sheet
ing from cord, hepatomegaly, ab-
dominal mass, anal orifice defects
3.7 GUS is examined for presence of
external gentalia and any
anomalies
3.8 Musculoskeletal is examined for
Joint swelling and tenderness,
bone fracture
3.9 Integumentary is assessed for
jaundice, pallor, rash,
petechiae, laceration
3.10 CNS is examined for alertness,
presence of Increased or
decreased tone, depressed or
absent neonatal reflexes
4 RELEVANT INVESTIGATIONS 80%
ARE DONE FOR A PRETERM

7
NEONATE AT THE DAY OF
ADMISSION
4.1 Completed blood count with Triangulate
differential order sheet with
4.2 RBS investigation
papers
4.3 Blood culture if sepsis suspected Triangulate
4.4 Chest x-ray for newborn with the history and

7
respiratory distress physical exam-
ination findings
with the diagno-
sis and planned
investigation on
history sheet/
order sheet with
investigation
papers
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PRETERM NEO-
NATE
5.1 Gestational age (Term, preterm)
is determined
Triangulate the
5.2 Correct classification of birth history, physical
weight for GA is determined examination and
(Normal birth weight, LBW, VLBW, lab findings with
ELBW, macrosomia) the diagnosis on
5.3 Appropriateness of weight for age NICU admission
is determined ( AGA, SGA, LGA) history sheet
and order sheet
5.4 Additional diagnoses are
identified correctly
6 APPROPRIATE TREATMENT IS 80%
PROVIDED FOR A PRETERM
NEONATE ON THE IMMEDIATE
ADMISSION DAY
6.1 Newborn is cared under thermo
Triangulate the
neutral environment with (incuba-
order sheet with
tor/radiant warmer) with a set tem-
vital sign sheet
perature is provided at admission
6.2 Newborn with respiratory distress Triangulate
is provided with oxygen/CPAP the history
support and physical
examination
findings with
the diagnosis
on history sheet
with ordered
treatment on
order sheet
6.3 Feeding or maintenance fluid is Triangulate the
ini- tiated in the first hour of time between
admission neonate’s
admission time
on history sheet
6.4 Expressed breast milk is initiated with feeding
in the first 24 hours of life even order time on
as a drop when oral feeding is order sheet
not possible with feeding
initiation time
on medication
sheet or Feeding
chart
6.5 Guideline concordant antibiotics Triangulate
are started for preterm neonate the history
with sepsis and physical
examination
findings with
the diagnosis
on history sheet
with ordered
treatment on
order sheet with
medication sheet
6.6 Parents/ care takers are informed
History sheet/
and counseled about preterm
order sheet
newborn care
7 APPROPRIATE MONITIORING 80%
IS DONE FOR A PRETERM NEO-

7
NATE DURING HOSPITAL STAY
7.1 Vital signs are monitored every 3
hourly if the patient has required
respiratory support (oxygen/CPAP)
HR
RR
BP

7
Temperature
SpO2 (oxygen saturation) Triangulate
7.2 Vital signs are monitored at least Order sheet with
4 times if the newborn is stable Vital sign sheet
with no oxygen or CPAP
treatment
HR
RR
BP
Temperature
SpO2 (oxygen saturation)
7.3 Hydration status is assessed at
least eight hourly for neonate that
are under radiant warmer and
photo- therapy
7.4 Feeding intolerance is assessed Progress note
at least twice daily (presence of
abdominal distention, bilious or
bloody vomiting, bowel sound,
blood in the stool )
7.5 Weight is measured daily Triangulate
7.6 Urine out put is monitored daily order sheet with
and interpreted for ml/kg/hour Vital sign sheet
7.7 Daily progress evaluation is
made by a physician
7.8 For newborn where feeding is
not initiated or kept NPO reason Progress note
is identified
7.9 Daily evaluation is done for
jaun- dice (clinical/ laboratory)
7.10 Feeding and fluid intake is
revised daily with daily Triangulate
increment of fluid and feeds order sheet with
based on the proto- col(10- medication sheet
20ml/day) or feeding chart
7.11 Feeding is calculated based on
volume and calorie requirement
7.12 If jaundice is diagnosed photother- Triangulate
apy initiated the subjective
and objective
findings on the
progress notes
with the treat-
ment ordered on
the order sheets
7.13 For newborn less than 2000
Order sheet
grams KMC is provided
7.14 Brain ultrasound is done within Triangulate
seven days of life for newborns order sheet with
less than 1500grams (only for investigation
tertiary hospitals) papers
8 APPROPRIATE DISCHARGE 100%
CARE IS PROVIDED FOR A
PRETERM NEONATE
8.1 Clinical assessment is done to
confirm improvement before
discharge- weight, head circum-
ference, length are measured
and interpreted
8.2 List of diagnosis from admission
to discharge are identified
8.3 Proper counseling is given to
the mother or care taker
Discharge
Regarding KMC summary sheet
EBF until six month of age
Sunlight exposure
Vaccination

7
To get (ROP) screening/ ophthal-
mologic evaluation
To get ultrasound evaluation
for IVH
To get Neurodevelopmental
eval- uation
Medication to be taken at home
8.4 Iron and Vitamin D is given for
those less than 2000 grams after
2 weeks of birth or at discharge Discharge

7
summary sheet
8.5 Vaccination status of the neonate
is mentioned
8.6 Follow-up (appointment) is sched-
uled to high risk clinic with brain
ultrasound request
9 IDENTIFICATION OF 100%
PROVID- ER IS
DOCUMENTED FOR A
PRETERM NEONATE
9.1 Name and signature of the physi-
cian is clearly documented on all History sheet
admission history and P/E sheets
9.2 Name and Signature of the
physi- cian is clearly Progress note
documented on all progress
notes
9.3 Name and signature of the physi-
cian is clearly documented on all Order sheet
order sheets
9.4 Name and signature of the phy-
sician is clearly documented on Discharge sheet
discharge summary
9.5 Name and signature of the nurse is
Medication
clearly documented on all medica-
sheet
tion sheets
10 A PRETERM NEONATE DIED 15%
WHILE BEING MANAGED IN
THE UNIT
Total standards met per chart
Percentage

References:
National NICU Management pro-
tocol,, training manual 2021
Audit Tool: Hyperbiluribinimia
Facility name
Department/unit
Audit Topic Neonatal hyperbilirubinemia
Aim To improve the quality of clinical care provided for newborns admitted with diagnosis of hyperbilirubinemia
Objectives To ensure newborns admitted with hyperbilirubinemia are appropriately evaluated
To ensure newborns admitted with hyperbilirubinemia are appropriately investigated
To ensure newborns admitted with hyperbilirubinemia are appropriately treated
To ensure newborns admitted with hyperbilirubinemia are appropriately monitored
To ensure newborns admitted with hyperbilirubinemia receive appropriate discharge care
Period of Audit
Inclusion criteria All neonates admitted with a diagnosis of hyperbilirubinemia to NICU
Exclusion criteria (where applicable) Neonates who had additional diagnosis other than hyperbilirubinemia, Neonates who are observed and sent back to mother
with in 24 hours with no jaundice ,
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient
For the monitoring section, use data from the first seven days of patient’s admission
Perfor-
Data Source Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A NEONATE
WITH HYPERBILIRUBINEMIA
1.1 Name/identification
1.2 Age of the newborn at admission
NICU admis-
1.3 Gender of the newborn sion history
1.4 Date and time of birth sheet
1.5 Birth weight
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A NEONATE WITH
HYPERBILIRUBINEMIA

7
2.1 Place of delivery is identified (in
the facility, referred from other
facility or home )
2.2 Maternal age, parity, marital
status, occupation, address is
inquired

7
2.3 The history of antenatal care follow
up is assessed (Whether the mother
had ANC visits, number of visits,
ANC services she obtained and their
results - blood group and RH,
VDRL, HIV, HBSAG,TT vaccines)
NICU admis-
2.4 Mode of delivery is identified (C/S, sion history
Forceps, Vacuum, SVD) sheet
2.5 The presence of possible risk factors
for hyperbilirubinemia is assessed
(Rh & ABO incompatibility, sepsis,
breast feeding ( inadequate feeding),
breast milk, polycythemia, subgalial
hemorrhage (SGH), congenital hypo-
thyroidism etc..)
2.6 Symptoms of acute bilirubin enceph-
alopathy are Inquired (decreased
feeding, change in mentation, fever,
abnormal body movement , abnor-
mal posturing etc..)
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
NEONATE WITH HYPERBILIRU-
BINEMIA
3.1 Vital sign are measured
HR NICU
RR admission
history sheet
BP
and vital sign
Temperature sheet
SpO2 (oxygen saturation)
3.2 Anthropometric measurements are
taken and interpreted for GA
NICU admis-
Weight for GA sion history
Head circumference GA sheet
Length GA
3.3 Level of jaundice is assessed
3.4 Signs of acute bilirubin encepha-
lopathy are assessed (decreased or
increased tone, fever seizure, change
in mentation , opistotones posturing
etc..)
3.5 Hydration status is assessed
(pulse rate, volume, capillary
refill time, mucosa, fontanel)
3.6 Signs of birth injury are assessed(-
subgaleal hemorrhage, cephal
hematoma, )
3.7 Respiratory system is examined for NICU admis-
cyanosis, retractions, chest in sion history
draw- ing, apnea, tachyepnia, sheet
crepitation, and status of air entry
3.8 CVS is examined foe pulse rhythm
and volume, capillary refill time
and murmurs
3.9 Abdomen is examined for -bleeding
from cord, hepatomegally,
abdominal mass, anal orifice defects
3.10 GUS is examined for presence of
external gentalia and any
anomalies
3.11 MSS is examined for Joint swelling
and tenderness, bone fracture
4 RELEVANT LAB INVESTI- 80%
GATIONS ARE DONE FOR A
NEONATE WITH HYPERBILI-
RUBINEMIA AT THE DAY OF
ADMISSION
4.1 Bilirubin (direct and total) measured
4.2 Hematocrit level measured Triangulate
order sheet
4.3 Blood group and Rh factor deter-
with investi-
mined
gation papers
4.4 CBC, Peripheral morphology is done

7
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A NEONATE
WITH HYPERBILIRUBINEMIA
5.1 Gestational age (Term, preterm) Triangulate
is determined the history,
5.2 Correct classification of birth physical
weight for GA is determined examina-
(Normal birth weight, LBW, VLBW, tion and lab
ELBW, macro- somia) findings with
the diagnosis

8
on NICU
admission
history sheet
and order
sheet
5.3 Appropriateness of weight for age Triangulate
is determined ( AGA, SGA, LGA) the history,
physical
5.4 The cause of hyperbilirubinemia examina-
is determined tion and lab
findings with
5.5 Complications of the hyperbilirubin- the diagnosis
emia are correctly identified(acute on NICU
bilirubin encephalopathy if present ) admission
5.6 Additional diagnoses are history sheet
identified correctly (if present) and order
sheet
6 APPROPRIATE TREATMENT IS 80%
PROVIDED FOR A NEONATE
WITH HYPERBILIRUBINEMIA ON
IMMEDIATE ADMISSION DAY
6.1 Newborn is cared under thermoneu- Triangulate
tral enviroment order sheet
with V/S
sheet
6.2 Phototherapy or exchange transfu-
sion is initiated for newborn who Triangulate
fullfill the criteria ( based on order sheet
Butanic curve for those 35 weeks with progress
and above and based on the table for note
those <35 weeks of gestation)
6.3 For neonate who is under photother- Triangulate
apy insensible water loss is replaced order sheet
with additional feed or fluid with medica-
tion sheet
6.5 Consent is taken before Newborn
exchange transfusion chart /con-
sent form
6.6 Age and volume of blood for ex- Triangulate
change transfusion is determined progress note
with order
sheet
6.7 Triangulate
the time
between neo-
nate’s admis-
sion time on
history sheet
with feeding
Feeding is started within the 1st order time on
24 hours of life with breast milk order sheet
with feeding
initiation
time on med-
ication sheet
or Feeding
chart

6.8 Feeding is held 2-3 hours before Triangulate

and after exchange transfusion order sheet
with medica-
tion sheet
6.9 Counseling and education about
History
jaundice in newborn and the care
sheet/ order
while under phototherapy is given
sheet
for mother/care taker
7 APPROPRIATE MONITIORING IS 80%
DONE FOR A NEONATE WITH
HYPERBILIRUBINEMIA DURING
HOSPITAL STAY
7.1 For newborn with acute bilirubin
encephalopathy for whom
exchange transfusion is done, vital Triangulate
signs are monitored every one hour progress note
with order

8
until stabilization ( seizure
controlled, feeding initiated, sheet with
normalized blood sugar etc...) vital sign
sheet
HR (Heart Rate)
RR
BP
Temperature
SpO2 (oxygen saturation)
7.2 Vital sign are monitored 4 times per Triangulate
day after stabilization progress note
with order

8
HR sheet with
RR vital sign
BP sheet
Temperature
SpO2 (oxygen saturation)
7.3 Daily progress evaluation is done
Progress note
by the physician
7.4 Daily weight measurement is done Progress
note/ vital
sign sheet
7.5 Neonate who is under radiant warm-
er and phototherapy, hydration status Progress note
is assessed at least six hourly

7.6 Hematocrit level is measured on

daily basis till jaundice decreases Triangulate
progress note
7.7 For neonate who is underphotother- with order
apy,Bilirubin (total) is measured on sheet with
daily basis in the 1st 3-5 days or investigation
until bilirubin level drops below papers
photo range

8 APPROPRIATE DISCHARGE CARE 100%

IS PROVIDED FOR A NEONATE
WITH HYPERBILIRUBINEMIA
8.1 Clinical assessment is done to con-
firm improvement before discharge
(discharge weight, head circum-
france,length, seizure control status
with the minimum dose of anticon-
vulsant)
8.2 Additional appointment is given to
neurology clinic for those babies
discharged with persisted acute bili-
rubin encephalopathy or kernicteres
8.3 List of diagnosis from admission
to discharge identified
8.4 Proper counseling on home care is
Discharge
given to the mother
summary
On danger signs and when to return sheet
EBF until six month of age
Sunlight exposure starting on the
next day after discharge
Vaccination
To come to follow-up clinic
with investigation results
8.5 Vaccination status of the neonate
is mentioned
8.6 Follow-up (appointment) is sched-
uled to high risk clinic with bilirubin
and hematocrit request paper
9 APPROPRIATE REFERRAL IS 100%
MADE TO A HIGHER LEVEL
INSTITIUTION FOR A
NEONATE WITH
HYPERBILIRUBINEMIA WITH
INDICATION (ONLY FOR
PRIMARY HOSPITAL)
9.1 Neonate who developed acute bilru- Triangulate
bin encephalopathy is referred for diagnosis on
exchange transfusion after correction history sheet/
of acute metabolic complications progress note

8
(Hypoglycemia, hypothermia, hyper- with referral
thermia, seizure) paper
10 IDENTIFICATION OF PROVID- 100%
ER IS DOCUMENTED FOR A
NEONATE WITH HYPERBILIRU-
BINEMIA
10.1 Name and signature of the
Admission
physician is clearly documented on

8
History sheet
all admis- sion history and P/E
sheets
10.2 Name and signature of the physician
is clearly documented on all Progress note
progress notes
10.3 Name and signature of the
physician is clearly documented on Order sheet
all order sheets
10.4 Name and signature of the
Discharge
physician is clearly documented on
summary
discharge summary
10.5 Name and signature of the
Referral
physician is clearly documented on
paper
referral paper
10.6 Name and signature of the nurse is
Medication
clearly documented on all medica-
sheet
tion sheets
11 NEONATE DIAGNOSED WITH 5%
HYPERBILRUBINIMIA DIED
WHILE BEING MANAGED IN THE
HEALTH FACILITY
Total standards met per chart
Percentage

References:
National NICU Management protocol,, training manual 2021
Audit Tool: PNA
Facility name
Department/unit
Audit Topic Birth asphyxia
Aim To improve the quality of clinical care provided for neonates admitted with the diagnosis of birth asphyxia
Objectives To ensure neonates with birth asphyxia are appropriately evaluated
To ensure neonates with birth asphyxia are appropriately investigated
To ensure neonates with birth asphyxia are appropriately treated
To ensure neonates with birth asphyxia are appropriately monitored
To ensure neonates with birth asphyxia receive appropriate discharge care
Period of Audit
Inclusion criteria All neonates admitted with a diagnosis of birth asphyxia to NICU
Exclusion criteria (where applicable) Death on arrival, those who are observed and sent back to mother or discharged with in 24 hours
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
For the monitoring section, use data from the first seven days of patient’s admission
Perfor-
Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target perfor- Remark
and verification against
mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A NEONATE
WITH BIRTH ASPHYIXA
1.1 Name/identification
1.2 Age of the newborn at admission
NICU admis-
1.3 Gender of the newborn sion history
1.4 Date and time of birth sheet
1.5 Birth weight
2 APPROPRITAE HISTORY IS 100%
TAKEN FOR A NEONATE WITH
BIRTH ASPHYIXA
2.1 Place of delivery is identified (in NICU admis-

8
the facility, referred from other sion history
facility or home ) sheet
2.2 Maternal age, parity, marital
status, occupation, address are
asked
2.3 The history of antenatal care follow
up is assessed (Whether the mother
had ANC visits, number of visits,

8
ANC services she obtained and their
results - blood group and RH,
VDRL, HIV, HBSAG,TT vaccines)
2.4 The presence of possible risk
factors is assessed- (prolonged
labor, obstructed labor, cord
accident, APH….)
2.5 The circumstances around the labor
are asked (onset of labor(induced or
spontaneous, duration of labor)
2.6 Whether there was fetal distress NICU admis-
during labor and color of liquoir sion history
during labour is determined sheet
2.7 Mode of delivery is identified (C/S,
Forceps, Vacuum, SVD)
2.8 APGAR score (1st minute, 5th min-
ute and 10th minute) or whether the
neonate cried at birth is determined
2.9 Whether there was a need for
resuscitation in the labor ward is
determined
level of resuscitation provided
is described (one or more of the
following -initial steps, PPV, PPV
with chest compression, adrenaline
provided, intubation)
Duration of resuscitation is men-
tioned
3 APPROPRITAE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
NEONATE WITH BIRTH ASPHY-
IXA
3.1 Vital signs are measured
NICU admis-
HR (Heart Rate) sion history
RR sheet and
BP vital sign
sheet
Temperature NICU admis-
SpO2 (oxygen saturation) sion history
sheet and
vital sign
sheet
3.2 Anthropometric measurement
are taken and interpreted for GA
(weight, HC, length)
Weight for GA
NICU admis-
Head circumference GA sion history
Length GA sheet
3.3 Signs of birth injury are assessed(-
subgaleal hemorrhage, cephalic
hematoma, )
3.4 Respiratory system is examined for
cyanosis, retractions, chest in
draw- ing, apnea, tachyepnia,
crepitation, and status of air entry
3.5 CVS is examined for pulse rhythm
and volume, capillary refill time
and murmurs
3.6 Abdomen is examined for -hepato-
megally, abdominal mass, anal
orifice defects NICU admis-
3.7 GUS is examined for presence of sion history
external gentalia and any sheet
anomalies
3.8 MSS is examined for Joint swelling
and tenderness, bone fracture
3.9 Integumentary is assessed for
jaundice, pallor, rash,
petechiae, laceration
3.10 CNS is examined for alertness, pres-
ence of Increased or decreased tone,
depressed or absent neonatal
reflexes
4 RELEVANT INVESTIGATIONS 80%

8
ARE DONE FOR A NEONATE
WITH BIRTH ASPHYIXA AT THE
DAY OF ADMISSION
4.1 CBC with differential Triangulate or-
4.2 RBS measured at least once per der sheet with
24 hours or frequently if investigation
indicated papers
4.3 BUN, creatinine, serum Triangulate or-
electrolyte done at 24 to 48 hours der sheet with
of life investigation
papers
4.4 If newborn has seizure, RBS and
serum calcium is determined at the

8
time of seizure Triangulate
the history
and physical
4.5 CRP, blood culture if sepsis suspected examination
findings with
the diagnosis
and planned in-
vestigation on
history sheet/
4.6 Chest x-ray for newborn with respi- order sheet
ratory distress with investiga-
tion papers

5 APPROPRIATE DIAGNOSIS IS 100%

MADE FOR A NEONATE
WITH BIRTH ASPHYIXA
5.1 Gestational age (Term, preterm)
is determined Triangulate
5.2 Correct classification of birth the history,
weight for GA is determined physical exam-
(Normal birth weight, LBW, VLBW, ination and lab
ELBW, macro- somia) findings with
the diagnosis
5.3 Appropriateness of weight for age
on NICU ad-
is determined ( AGA, SGA, LGA)
mission history
5.4 Stage of PNA is identified sheet and order
5.5 Additional diagnoses are sheet
identified correctly (if present)
6 APPROPRIATE TREATMENT IS 100%
PROVIDED FOR A NEONATE
WITH BIRTH ASPHYIXA ON THE
IMMEDIATE ADMISSION DAY
6.1 Newborn is cared under thermoneu- Triangulate
tral environment(radiant warmer, the order sheet
incubator or with mother) with a set with vital sign
temperature of 36.5 sheet
6.2 Newborn with respiratory distress is Triangulate
provided with oxygen/CPAP support the history and
6.3 If the newborn is unable to suck physical exam-
NG tube is inserted ination findings
with the
diagnosis on
history sheet
with ordered
treatment on
order sheet
6.6 Feeding or maintenance fluid initiat- Triangulate the
ed in the first hour of admission time between
neonate’s
admission
time on history
sheet with
feed- ing order
time on order
sheet with
feeding
initiation time
on medication
sheet or Feed-
ing chart
6.7 Maintenance fluid is initiated with Triangulate
60ml/kg of 10 % dextrose with the order sheet
calci- um gluconate with medica-
tion sheet

8
6.8 Antibiotics are started if sepsis
is suspected Triangulate
the history and
6.9 Optimal treatment is given for a physical exam-
neonate who has seizure ination findings
RBS checked at the time of seizure with the
and corrected if it is below diagnosis on

9
40mg/dl history sheet
Calcium gluconate is given for with ordered
sei- zure if RBS is normal treatment on
order sheet
Phenobarbiton loading of 20mg/dl with medica-
provided for seizure management tion sheet
maintenance phenobarbitone is start-
ed after loading dose
6.10 Counseling and education given to
History sheet/
mother/care taker about their sick
order sheet
newborn
7 APPROPRIATE MONITORING IS 100%
DONE FOR A NEONATE WITH
BIRTH ASPHYIXA DURING HOS-
PITAL STAY
7.1 Vital signs are monitored every 3
hourly if the patient has required
respiratory support (oxygen/CPAP)
HR
RR
BP
Temperature
SpO2 (oxygen saturation) Triangulate
Order sheet
7.2 Vital signs are monitored at least with vital
6hourly if the newborn is stable sign sheet
with no oxygen or CPAP treatment
HR
RR
BP
Temperature
SpO2 (oxygen saturation)
7.3 Hydration status is assessed at
least eight hourly for neonate that
are under radiant warmer and
photo- therapy
7.4 Feeding intolerance is assessed at Progress note
least twice daily (presence of
abdom- inal distention, bilious or
bloody vomiting, bowel sound,
blood in the stool )
7.5 Weight is measured daily Triangulate
7.6 Urine out put is monitored daily and order sheet
interpreted for ml/kg/hour with Vital sign
sheet
7.7 Daily progress evaluation is made
by a physician
7.8 For newborn where feeding is
not initiated or kept NPO reason Progress note
is identified
7.9 Daily evaluation is done for
jaundice (clinical/ laboratory)
7.10 Feeding and fluid intake is Triangulate or-
revised daily with daily der sheet with
increment of fluid and feeds medication
based on the proto- col(10- sheet or
20ml/day) feeding chart
7.11 If jaundice is diagnosed phototherapy Triangulate
initiated the subjective
and objective
findings on the
progress notes
with the treat-
ment ordered
on the order
sheets
8 APROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A NEONATE
WITH BIRTH ASPHYIXA

9
8.1 Discharge diagnosis (Pertinent list
of diagnosis from admission to
dis- charge) are identified
8.2 Discharge Wt, HC, length are
docu- mented
8.3 Proper counseling is provided to the

9
mother or caretaker
On danger signs and when to return
EBF until six month of age
Sunlight exposure
Vaccination Discharge
Importance of follow-up to high summary sheet
risk clinic
Having regular neurodevelopmental
evaluation
8.4 Medication to be taken at are docu-
mented if discharged with anticon-
vulsant
8.5 Vaccination status of the neonate
is mentioned
8.6 Appointment is given with
date mentioned
9 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A NEO-
NATE WITH BIRTH ASPHYIXA
9.1 Name and signature of the
physician is clearly documented on History sheet
all admis- sion history and P/E
sheets
9.2 Name and signature of the physician
is clearly documented on all Progress note
progress notes
9.3 Name and signature of the
physician is clearly documented on Order sheet
all order sheets
9.4 Name and signature of the
physician is clearly documented on Discharge sheet
discharge summary
9.5 Name and signature of the nurse is
Medication
clearly documented on all medica-
sheet
tion sheets
10 A NEONATE WITH BIRTH 15%
ASPHYXIA DIED WHILE BEING
TREATED IN THE HEALTH FA-
CILITY
Total standards met per chart
Percentage

References:
National NICU Management proto-
col,, training manual 2021

9
Audit Tool: Neonatal Sepsis
Facility name
Department/unit
Audit Topic Neonatal sepsis
Aim To improve the quality of clinical care provided for neonates admitted with the diagnosis of sepsis (suspected and proven)

9
Objectives To ensure neonates with suspected or proven sepsis are appropriately evaluated
To ensure neonates with suspected or proven sepsis are appropriately investigated
To ensure neonates with suspected or proven sepsis are appropriately treated
To ensure neonates with suspected or proven sepsis are appropriately monitored
To ensure neonates with suspected or proven sepsis receive appropriate discharge care
Period of Audit
Inclusion criteria All neonates admitted with a diagnosis of neonatal sepsis to NICU
Exclusion criteria (where applicable) Death on arrival, those who are observed and sent back to mother or discharged with in 24 hours
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individu- al patient
For the monitoring section, use data from the first seven days of patient’s admission
Perfor-
Data Source Actual
Target

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
NEONATE WITH SEPSIS
1.1 Name/identification
1.2 Age of the newborn at admission
NICU admis-
1.3 Gender of the newborn sion history
1.4 Date and time of birth sheet
1.5 Birth weight
2 APPROPRITAE HISTORY IS 100%
TAKEN FOR A NEONATE
WITH SEPSIS
2.1 Place of delivery is identified
(in the facility, referred from
other facility or home )
2.2 Maternal age, parity, marital
sta- tus, occupation, address is
asked
2.3 The history of antenatal care
follow up is assessed (Whether
the mother had ANC visits, num-
ber of visits, ANC services she
obtained and their results - blood
group and RH, VDRL, HIV,
HBSAG,TT vaccines) NICU admis-
sion history
2.4 The presence of possible risk sheet
factors is assessed- (premature
rupture of membrane, mater-
nal chorioamnionitis, maternal
infection )
2.5 Duration of rupture of mem-
brane is determined
2.6 The circumstances around the
labour are assessed (onset of
labor(induced or spontaneous,
duration of labor)
2.7 Mode of delivery is
identified (C/S, Forceps,
Vacuum, SVD)
3 APPROPRITAE PHYSICAL EX- 100%
AMINATION IS PERFORMED
FOR A NEONATE WITH
SEPSIS
3.1 Vital signs are measured
HR (Heart Rate)
NICU admis-
RR sion history
BP sheet and
Temperature vital sign
sheet
SpO2 (oxygen saturation)

9
3.2 Anthropometric measurements
are taken and interpreted for GA
(weight, HC, length) NICU admis-
Weight for GA sion history
sheet
Head circumference GA
Length GA
3.3 Signs of birth injury are as-
sessed(subgaleal hemorrhage,
cephalic hematoma, )
3.3 Respiratory system is examined
for cyanosis, retractions, chest in
drawing, apnea, tachypnea,

9
crepi- tation, and status of air
entry
3.4 CVS is examined for pulse
rhythm and volume, capillary
refill time and murmurs
3.5 Abdomen is examined for
distension, absent or decreased
bowel sound, cord bleeding , NICU admis-
rectal bleeding, bleeding from sion history
the stomach, pus from the sheet
umbilical stamp and erythema.
3.6 GUS is examined for presence
of external gentalia and any
anomalies
3.7 MSS is examined for Joint swell-
ing and tenderness, bone fracture
3.8 Integumentary is assessed for
jaundice, pallor, rash,
petechiae, laceration
3.9 CNS is examined for alertness,
presence of Increased or de-
creased tone, depressed or
absent neonatal reflexes
4 RELEVANT INVESTIGATIONS 80%
ARE DONE FOR A NEONATE
WITH SEPSIS AT DAY OF
ADMISSION
4.1 CBC with differential Triangulate or-
4.2 CRP der sheet with
investigation
4.3 Blood culture papers
4.4 CSF analysis and culture based Triangulate
on the guideline (if neonate the history
presented after 72 hours of life and physical
or has sever sepsis or has signs examination
of meningitis) findings with
4.5 RFT based on the guideline the diagnosis
(If Renal insult is present) and planned
4.6 Chest x-ray for newborn with investigation
respiratory distress or suspected on history
pneumonia sheet/order
sheet with
4.7 Abdominal X-Ray- if NEC investigation
is suspected ) papers
5 APPROPRIATE DIAGNOSIS 100%
IS MADE FOR A NEONATE
WITH SEPSIS
5.1 Gestational age (Term, preterm)
is determined
5.2 Triangulate
Correct classification of
the history,
birth weight for GA is
physical exam-
determined (Normal birth
ination and lab
weight, LBW, VLBW,
findings with
ELBW, macrosomia)
the diagnosis
5.3 Appropriateness of weight for on NICU
age is determined ( AGA, SGA, admission his-
LGA) tory sheet and
5.4 Presumed type of sepsis is order sheet
deter- mined
5.5 Additional diagnoses are identi-
fied correctly (if present)
6 APPROPRIATE TREATMENT 100%
IS PROVIDED FOR A NEO-
NATE WITH SEPSIS ON THE
IMMEDIATE ADMISSION DAY
6.1 Newborn is cared under ther- Triangulate
moneutral environment(radiant the order sheet
warmer, incubator or with moth- with vital sign
er) with a set temperature of sheet
36.5
6.2 Newborn with respiratory Triangulate
distress is provided with the history and
oxygen/ CPAP support physical exam-
6.3 If the newborn is unable to suck ination find-
NG tube is inserted ings with the
diagnosis on
history sheet
with ordered
treatment on
order sheet

9
6.4 Guideline concordant antibiotics Triangulate the
are started time between
neonates ad-
mission time
on history
sheet with an-
6.5 Antibiotics are started with in tibiotics order

9
1 hour of admission time on order
sheet with
initiation time
on medication
sheet
6.6 Feeding or maintenance fluid Triangulate the
initiated in the first hour of time between
admission neonates
admission
time on
history sheet
with feeding
order time on
order sheet
with feeding
initiation time
on medication
sheet or Feed-
ing chart
6.7 Counseling and education given
History sheet/
to mother/care taker about their
order sheet
sick newborn
7 APPROPRIATE MONITORING 100%
IS DONE FOR A NEONATE
WITH SEPSIS DURING HOSPI-
TAL STAY
7.1 Vital signs are monitored every
3 hourly if the patient has
required respiratory support
(oxygen/ CPAP)
Triangulate
HR Order sheet
RR with vital
sign sheet
BP
Temperature
SpO2 (oxygen saturation)
7.2 Vital signs are monitored at
least 6hourly if the newborn is
stable with no oxygen or
CPAP treatment
Triangulate
HR Order sheet
RR with vital
sign sheet
BP
Temperature
SpO2 (oxygen saturation)
7.3 Hydration status is assessed at
least eight hourly for neonate
that are under radiant warmer
and phototherapy
7.4 Feeding intolerance is assessed Progress note
at least twice daily (presence of
abdominal distention, bilious or
bloody vomiting, bowel sound,
blood in the stool )
7.5 RBS is measured at least every24
hour Triangulate
the order sheet
7.6 Weight is measured daily
with Vital sign
7.7 Urine out put is monitored daily sheet
and interpreted for ml/kg/hour
7.8 Daily progress evaluation is
made by a physician
7.9 For newborn where feeding is
not initiated or kept NPO reason
is identified
7.1 Clinical assessment for Progress note
complica- tions (DIC, apnea,
thrombocyto- penia, seizure ,
etc..) is made on daily basis
7.11 If antibiotics is changed
reason for change is
documented
7.12 Neurosign chart monitoring is
Neurosign

9
done every 24 hours, for a
chart
neo- nate with meningitis
8 APROPRIATE DISCHARGE 100%
CARE IS PROVIDED FOR A
NEONATE WITH SEPSIS
8.1 Discharge diagnosis (Pertinent
list of diagnosis from
admission to discharge) are
identified
8.2 Discharge Wt, HC, length
are documented

1
8.3 Proper counseling is provided to
the mother or caretaker
On danger signs and when to
return
EBF until six month of age
Sunlight exposure Discharge
summary
Vaccination sheet
Importance of follow-up to high
risk clinic
Having regular neurodevelop-
mental evaluation
8.4 Vaccination status of the
neonate is mentioned
8.5 Follow-up (appointment sched-
uled) to high risk infant clinic
is given for neonate with sever
sepsis (meningitis, seizure
stage II and III NEC)
9 IDENTIFICATION OF PRO- 100%
VIDER IS DOCUMENTED
FOR A NEONATE WITH
SEPSIS
9.1 Name and signature of the
physician is clearly documented
History sheet
on all admission history and P/E
sheets
9.2 Name and signature of the physi-
cian is clearly documented on all Progress note
progress notes
9.3 Name and signature of the phy-
sician is clearly documented on Order sheet
all order sheets
9.4 Name and signature of the phy-
Discharge
sician is clearly documented on
sheet
discharge summary
9.5 Name and signature of the nurse
Medication
is clearly documented on all
sheet
medication sheets
10 A NEONATE WITH SEPSIS 15%
DIED WHILE BEING TREAT-
ED IN THE HEALTH FACILITY
Total standards met per chart
Percentage

References:
National NICU Management protocol,, training manual
2021

1
Audit Tool: SAM
Facility name
Department/unit
Audit Topic Severe acute malnutrition (pediatric patients)
Aim To improve the quality clinical care provided for pediatrics patients diagnosed and admitted with SAM

1
Objectives To ensure pediatric patients admitted with SAM have appropriate inpatient evaluation
To ensure pediatric patients admitted with SAM are appropriately investigated
To ensure pediatric patients admitted with SAM receive appropriate inpatient management
To ensure pediatric patients admitted with SAM receive appropriate inpatient monitoring/follow-up
To ensure pediatric patients admitted with SAM receive appropriate discharge care
Period of Audit
inclusion criteria All pediatric patients with a diagnosis of SAM and admitted to stabilization center
Exclusion criteria (where applicable) children aged <six month and > than 60 month
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individ- ual patient
Perfor-
Data Source Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and Verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A PE-
DIATIRC PATIENT WITH SAM
1.1 Name
1.2 Age
Inpatient
1.3 Sex admission
1.4 Date history sheet
1.5 MRN
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A PEDIATIRC PA-
TIENT WITH SAM
2.1 Nutritional history is taken ( breast
feeding, complimentary feeding,
type and frequency of feeds, plate
sharing)
2.2 Symptoms of complications are in-
quired-(cough, fast breathing, skin
lesions, eye lesions, body swell-
ing, diarrhea, vomiting, altered
mentation) Inpatient
admission
2.3 History of chronic illnesses are history sheet
inquired
2.4 Immunization history is assessed
(age appropriate number of visit
for vaccination)
2.5 Social history is assessed ( family
size, source of income, living
con- ditions)
3 APPROPRIATE PHYSICAL 100%
EXAMINATION IS PERFORMED
FOR A PEDIATIRC PATIENT
WITH SAM
3.1 Vital signs are measured
PR Inpatient
RR admission
history sheet
BP
and vital
Temperature sign sheet
Oxygen saturation(PSO2)
3.2 Anthropometric measurements
are taken and interpreted based on
WHO curves
Weight for age
length/height for age
Weight for height/length Inpatient
HC for age admission
history sheet
BMI for age ( for age >2yrs)
MUAC for age

1
3.3 Eyes are assessed for signs of vita-
min A deficiency
3.4 Chest is auscultated
3.5 CVS is assessed for (capillary refill,
Rate and strength of the pulse),
precordium is auscultated
Inpatient
3.6 Extremities are assessed for edema admission
3.7 Skin is assessed for skin lesions history sheet
3.8 Skin is assessed for palmar pallor

1
3.9 Signs of dehydration are assessed
4 RELEVANT INVESTIGATIONS 90%
ARE DONE FOR A PEDIATIRC
PATIENT WITH SAM
4.1 CBC, blood group and RH Triangulate
4.2 Urine analysis planned in-
vestigations
4.3 stool examination on inpatient
4.4 HIV test order sheet
with inves-
tigations
papers
4.5 Chest x ray for a patient with Triangulate
respi- ratory complaint or chest history and
findings) diagnosis
on inpatient
admission
4.6 Renal function test( for pts history sheet
presenting with dehydration and with planned
shock) investiga-
tions on
order sheet
with inves-
tigations
papers
5 APPROPRIATE DIAGNOSIS 100%
IS MADE FOR A PEDIATIRC
PATIENT WITH SAM
5.1 Degree of malnutrition is Triangulate
clearly identified the history,
physical
examination
and investi-
gation find-
ings with the
5.2 Existing complications are
diagnosis on
correct- ly identified
the Inpatient
admission
history sheet/
order sheet
6 APPROPRIATE TREATMENT IS 100%
PROVIDED FOR A PEDIATIRC
PATIENT WITH SAM
6.1 Nutritional management is started Triangulate
based on weight the inpa-
tient order
sheet with
nutritional
management
on the multi-
chart
6.2 First line antibiotics are given Triangulate
as per the protocol the history,
6.3 Vitamin A is administered for physical
child with eyes signs of vit A examina-
deficiencies tion and
investigation
6.4 Blood transfusion is made for findings on
a patient with Hg<4mg/dl inpatient
6.5 Complications, if present are admission
managed according to national history sheet
guideline with order
sheet with
medication
sheet
7 APPROPRIATE MONITORING 100%
IS DONE FOR A PEDIATIRC
PATIENT WITH SAM

1
DURING HOSPITAL STAY
7.1 Follow up of is made using multi-
car (All parameters of the multich-
Multichart
art are filled as per the time frame
provided in the multi chart
7.2 Iron started in phase 2 for anemic
patient Triangulate
inpatient

1
7.3 Nutritional shift is made as per the
order sheet/
guideline
multichart
7.4 Dewarming is done in phase 2 with medica-
as per the guideline tion sheet

8 APPROPRIATE DISCHARGE 100%

CARE IS PROVIDED FOR A PE-
DIATIRC PATIENT WITH SAM
8.1 Clinical assessment is done to con-
firm improvement before
discharge (complications are
resolved, Pa- tient able to take
weight appropri- ate amount of
RUTF daily )
8.2 Discharge anthropometry is Discharge
checked and met WHO’s stan- summary
dard(wt/in or height above -3SD )
8.3 Nutritional counseling is provided
8.4 Appointment date is given
8.5 RUTF is supplied or linked
to other facilities
9 IDENTIFICATION OF PRO- 100%
VIDER IS DOCUMENTED FOR
A PEDIATIRC PATIENT WITH
SAM
9.1 Name and signature of the physi-
Inpatient
cian is clearly documented on all
history sheet
admission history and P/E sheets
9.2 Name and Signature of the
Progress
physi- cian is clearly
notes
documented on all progress
notes
9.3 Name and signature of the physi-
cian is clearly documented on all Order sheet
order sheets
9.4 Name and signature of the phy- Discharge
sician is clearly documented on summary
discharge summary sheet
9.5 Name and signature of the nurse is
Medications
clearly documented on all medica-
sheet
tion sheets
10 A PEDIATIRC PATIENT WITH 100%
SAM CLINICALLY IMPROVED
(COMPLICATIONS ARE RE-
SOLVED AND PATIENT ABLE
TO TAKE WEIGHT APPROPRI-
ATE AMOUNT OF RUTF DAILY
AND WT/LN OR HEIGHT IS
ABOVE -3SD )
Total standards met per chart
Percentage

References:
National SAM management training manual

1
Audit Tool: AGE
Department/unit
Audit Topic AGE (pediatric patients)
Aim To Improve the quality of clinical care provided to pediatrics patients with AGE
Objectives To ensure pediatrics patients admitted to ED with AGE are appropriately evaluated

1
To ensure pediatrics patients admitted to ED with AGE are appropriately Investigated
To ensure pediatrics patients admitted to ED with AGE are appropriately treated
To ensure pediatrics patients admitted to ED with AGE are appropriately monitored
To ensure pediatrics patients admitted to ED with AGE receive appropriate discharge care
Period of Audit
inclusion criteria Pediatric patients admitted to ED with the diagnosis of AGE
Exclusion criteria (where applicable) AGE patients with no dehydration, AGE with shock
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient

perfor- mance
Performance
Tar- Data Source and
No Standards/criteria Remark

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19

against
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
get verification

Actual

target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PEDIATRIC
PATIENT WITH AGE
1.1 Name
1.2 Age
1.3 Sex ED History sheet
1.4 Date
1.5 MRN
2 APPROPRIATE HISTORY IS TAK- 100%
EN FOR A PEDIATRIC PATIENT
WITH AGE
2.1 The diarrhea is well described -
dura- tion, amount, frequency,
consistency, color ( bloody, mucoid)
2.2 Associated symptoms – fever, vomit-
ing abdominal pain or sudden attacks
of inconsolable crying in infants are
identified
2.3 History of complications are inquired
– eagerness to drink, change in
behavior, change in mentation
2.4 Immunization history is taken
ED History sheet
2.5 Nutritional history is taken ( breast
feeding, complimentary feeding,
frequency and type of feeding)
2.6 Presence of recent cholera
outbreak in their vicinity is
inquired
2.7 Food preparing practices in the
house is assessed( to assess
hygiene)
2.8 Social history is taken ( family size,
water source, waste disposal
mecha- nism, toilet)
3 APPRORIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
PEDIATRIC PATIENT WITH AGE
3.1 Vital signs are measured
PR
RR ED Admission his-
tory sheet and ED
BP
vital sign sheet
Temperature
SpO2 (oxygen saturation)
3.2 Anthropometry measurements are
taken and interpreted
Weight for age
length/height for age

1
Weight for height/length ED History sheet
HC for age
BMI for age ( for age >2yrs)
MUAC for age
3.3 Dehydration status of the patient is
assessed (skin pinch, oral mucosa,
sunkening of eyes)
3.4 Patient is assessed for signs of shock ED History sheet
(strength and rate of the pulse, capil-
lary refill, mentation, touch tempera-
ture of extremities)

1
4 RELEVANT INVESTIGATIONS 100%
ARE DONE FOR A PEDIATRIC
PATIENT WITH AGE
4.1 CBC Triangulate ED
4.2 Stool examination order sheet with
investigation papers
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PEDIATRIC PA-
TIENT WITH AGE
5.1 Degree of dehydration is Triangulate the
correctly identified history and phys-
5.2 Complications are identified cor- ical examination
rectly findings with the
diagnosis on the
ED history sheet
6 APPROPRIATE TREATMENT IS 100%
PROVIDED FOR A PEDIATRIC
PATIENT WITH AGE
6.1 Correct rehydration plan carried out Triangulate the
( type of fluid, route and dose) as dehydration status
per the national guideline on the diagnosis
with the rehydration
treatment carried
out on order sheet /
vital sheet/ progress
note
6.2 Oral Feeding is continued (Contin-
Order sheet
ued feeding/ breast feeding)
6.3 Zinc is given
6.4 Antibiotics are initiated if
indicat- ed(GI onset sepsis, Triangulate order
dysentery are diagnosed sheet with medica-
6.5 Those who deserve admission ( with tion sheet
SAM, dysentery , sepsis) are
admitted or referred
7 APPROPRIATE MONITORING 100%
IS DONE FOR A PEDIATRIC
PATIENT WITH AGE
DURING HOSPITAL STAY
7.1 Vital signs are monitored as per
the guideline
PR
RR
BP
Temperature
SpO2 (oxygen saturation)
7.2 Oral mucosa and skin pinch are
checked as per the guideline Rehydration chart
7.3 Urine out put is monitored as per the
guideline
7.4 Weight gain is monitored as per
the guideline
7.5 Fontanel are checked as per
the guideline
7.6 Mentation is assessed as per
the guideline
8 APPROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A PEDIATRIC
PATIENT WITH AGE
8.1 Clinical assessment is done to con-
firm improvement before
discharge (stable vital signs and
out of dehy- dration )
8.2 Parents are counseled on avoiding Progress note
risk factors and what to do in another
attack of diarrhea
8.3 ORS and Zinc is provided
9 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A PEDI-
ATRIC PATIENT WITH AGE

1
9.1 Name and signature of the
physician is clearly documented on History sheet
all history and P/E sheets
9.2 Name and Signature of the
physician is clearly documented on Progress notes
all progress notes

1
9.3 Name and signature of the
physician is clearly documented on Order sheet
all order sheets
9.4 Name and signature of the physi-
cian is clearly documented on the Discharge summary
discharge summary
9.5 Name and signature of the nurse is
clearly documented on all medica- Medications sheet
tion sheets
10 A PEDIATRIC PATIENT WITH 100% Stable vital signs
AGE IMPROVED AND DIS- and out of dehydra-
CHARGED tion
Total standards met per chart
Percentage

References:
IMNCI Chart Booklet 2021
WHO pocket book
Audit Tool: Pneumonia
Facility name
Department/unit
Audit Topic Severe and very severe pneumonia (pediatric patients)
Aim To improve the quality of clinical care for pediatrics patients diagnosed with severe and very severe pneumonia
Objectives To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia are appropriately evaluated
To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia are appropriately investigated
To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia are appropriately treated
To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia are appropriately monitored
To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia are appropriately referred
To ensure pediatrics patients admitted to the ED and then ward with severe pneumonia receive appropriate discharge care
Period of Audit
inclusion criteria Pediatric patients with the diagnosis of severe and very severe pneumonia admitted to ED and then to ward
Exclusion criteria (where applicable) Pediatric patients with the diagnosis of non-severe pneumonia evaluated in the ED, Pediatric patients with the diagnosis of
severe pneumonia managed and discharged from the ED within in 48hours, Pediatric patients with severe and very severe
pneumonia whose is age greater than 5years old (60 months)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Actual Perfor-

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source and per- mance
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Remark
verification for- against
mance target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
PEDIATRIC PATIENT WITH
PNEUMONIA
1.1 Name
1.2 Age
1.3 Sex ED history sheet
1.4 Date
1.5 MRN
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A PEDIATRIC

1
PATIENT WITH PNEUMONIA
2.1 Cough is well characterized
(Duration of cough, intensity of
cough, type of cough)
2.2 Presence of fever is assessed
2.3 Presence of danger signs –
vom- iting everything,

1
convulsion, altered mentation
are assessed
ED history sheet
2.4 Immunization status is assessed
2.5 Nutritional history is taken(
breast feeding, complimentary
feeding, frequency, and
amount of feeding)
2.6 Social history is taken( Family
size, living conditions,
exposure to smoke)
3 APPROPRIATE PHYSICAL EX- 100%
AMINATION IS PERFORMED
FOR A PEDIATRIC PATIENT
WITH PNEUMONIA
3.1 Vital signs are taken
PR
ED Admission
RR history sheet and
BP ED vital sign
Temperature sheet
SpO2 (oxygen saturation)
3.2 Anthropometry measurement are
taken and interpreted
Weight for age
length/height for age
weight for height/length
HC for age
ED history sheet
BMI for age ( for age >2yrs)
MUAC for age
3.3 Signs of respiratory distress
are assessed( chest in
drawing,
cyanosis, grunting, flaring of
ala nasal, head nodding)
3.4 Chest is examined (inspection,
palpation, percussion, ausculta-
tion)
3.5 CVS is assessed for (capillary
refill, Rate and strength of the ED history sheet
pulse), precordium is auscultated
3.6 level of consciousness of the
child is evaluated
4 RELEVANT INVESTIGATIONS 100%
ARE DONE AT INITIAL EVAL-
UATION FOR A PEDIATRIC
PATIENT WITH PNEUMONIA
4.1 CBC Triangulate ED
order sheet with
investigation
paper
4.2 Chest x-ray is done if patient Triangulate diag-
has complications or additional nosis on ED his-
respiratory illness tory sheet with
ED order sheet
with radiology
request paper
5 APPROPRIATE DIAGNOSIS 100%
IS MADE FOR A PEDIATRIC
PATIENT WITH PNEUMONIA
5.1 Complications are Triangulate
identified correctly the history
5.2 Severity of the disease is and physical
identi- fied examination
findings with
the diagnosis on
the ED history
sheet
6 APPROPRIATE MANAGE- 80%
MENT IS PROVIDED FOR A
PEDIATRIC PATIENT WITH
PNEUMONIA
6.1 Oxygen administration is ordered
Triangulate ED

1
by the physician( amount/minute
order sheet with
and gadget i.e., cannula, prong,
medication sheet
face mask, etc.)
6.2 Feeding is continued or if the
patient is on Maintenance Fluid
ED order sheet
then type and amount of fluid is
documented.
6.3 Appropriate antibiotics are initi-
ated as per the national/ hospital
guideline

1
6.4 Antibiotics are administered at Triangulate ED
the correct dose, route, frequency order sheet with
and duration medication sheet

6.5 Antipyretics are used in the

pres- ence of high grade fever
7 APPROPRIATE MONITORING 100%
IS DONE FOR A PEDIATRIC
PATIENT WITH
PNEUMONIA DURING
HOSPITAL STAY
7.1 Vital signs are monitored at
least QID base
PR
Triangulate ward
RR order sheet with
BP vital sign sheet
Temperature
SpO2 (oxygen saturation)
7.2 Progress of the patient is Ward Progress
assessed daily until discharge note
7.3 Chest x-ray is done if there is no Triangulate the
response with initial treatment or diagnosis on the
patient develops complications ward progress
note with order
sheet with radi-
ologic request
paper
8 APPROPRIATE DISCHARGE 100%
CARE IS PROVIDED FOR A
PEDIATRIC PATIENT WITH
PNEUMONIA UP ON DIS-
CHARGE
8.1 Patient is given oral antibiotics Triangulate
if discharged without progress note
completing IV antibiotics with discharge
summary
8.2 Family is counseled on vaccina-
Discharge sum-
tion, sun exposure, and avoiding
mary
risk factors up on discharge
9 APPROPRIATE REFERRAL IS 100%
MADE TO A HIGHER LEV-
EL INSTITIUTION FOR A
PEDIATRIC PATIENT WITH
PNEUMONIA WHO HAS
INDI- CATION (ONLY FOR
PRIMA- RY HOSPITAL)
9.1 Patient diagnosed with impend- Triangulate the
ing respiratory failure or respira- diagnosis on the
tory failure is referred to a ward progress
higher institution with ICU set- note with referral
up paper
10 IDENTIFICATION OF PRO- 100%
VIDER IS DOCUMENTED FOR
A PEDIATRIC PATIENT WITH
PNEUMONIA
10.1 Name and signature of the physi-
cian is clearly documented on all History sheet
history and P/E sheets
10.2 Name and Signature of the
physi- cian is clearly Progress notes
documented on all progress
notes
10.3 Name and signature of the physi-
cian is clearly documented on all Order sheet
order sheets
10.4 Name and signature of the phy-
Discharge sum-
sician is clearly documented on
mary
discharge summary
10.5 Name and signature of the phy-
sician is clearly documented on Referral paper

1
referral paper
10.6 Name and signature of the nurse
is clearly documented on all Medication sheet
medication sheets
11 A PEDIATRIC PATIENT WITH 11%
PNEUMONIA DIED WHILE
BEING TREATED IN THE
HOSPITAL
Total standards met per chart
Percentage

1
References:
IMNCI Chart Booklet 2021
Nelson Textbook of Pediatrics
Audit Tool: Malaria
Facility
Department/unit
Audit Topic Severe and complicated malaria (pediatric patients)
Aim Improve the quality of clinical care given to pediatrics patients admitted with severe and complicated malaria
Objectives To ensure pediatric patients admitted with severe and complicated malaria are appropriately evaluated
To ensure pediatrics patients admitted with severe and complicated malaria are appropriately investigated
To ensure pediatrics patients admitted with severe and complicated malaria are appropriately managed
To ensure pediatrics patients admitted with severe and complicated malaria are appropriately monitored
To ensure pediatrics patients admitted with severe and complicated malaria receive appropriate discharge care
Period of Audit
inclusion criteria Pediatric patients admitted with severe and complicated malaria
Exclusion criteria (where applicable) Pediatric patients admitted with uncomplicated malaria , Pediatric patients with severe and complicated malaria whose age is
greater than 5years old (60 months)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
For monitoring section, use data from the first 7 days of admission of the patient to inpatient
Perfor-
Data Source Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
chart 1 mance
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
PEDIATIRC PATIENT WITH
MALARIA
1.1 Name
1.2 Age
1.3 Sex Inpatient
history sheet
1.4 Date
1.5 MRN
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A PEDIATIRC
PATIENT WITH MALARIA AT

1
ADMISSION
2.1 Duration and pattern of fever is Inpatient
assessed history sheet
2.2 The presence of chills and
rigors is assessed
2.3 Presence of myalgia and
arthral- gia is assessed
2.4 Presence of headache is assessed
2.5 Presence of altered mentation

1
and abnormal body movement is Inpatient
assessed history sheet

2.6 Nutritional history is taken

2.7 Whether or not the patient is
from malaria endemic area or
have history of travel to
malari- ous area is inquired
3 APPROPRIATE PHYSICAL EX- 100%
AMINATION IS PERFORMED
FOR A PEDIATIRC PATIENT
WITH MALARIA AT ADMIS-
SION
3.1 Vital signs are measured
PR
RR
BP
Temperature
SpO2 (oxygen saturation)
3.2 Anthropometry measurements
are taken and interpreted
Weight for age
length/height for age
Weight for height/length Inpatient
HC for age history sheet
BMI for age ( for age >2yrs)
MUAC for age
3.4 Eyes are assessed for conjunctival
pallor
3.5 Eyes are assessed for icteric
sclera
3.6 Chest is examined (palpation,
percussion, auscultation)
3.7 Precordium is auscultated
3.8 Abdomen is palpated Inpatient
3.9 Level of consciousness is assessed history sheet
3 RELEVANT INVESTIGATIONS 100%
ARE DONE FOR A PEDIATIRC
PATIENT WITH MALARIA AT
ADMISSION
3.1 CBC Triangu-
3.2 Blood film late order
sheet with
investigation
papers
3.3 Investigations relevant to identi- Triangulate
fied complications in history the history
and P/E are done and physical
examination
findings
with order
sheet and
investigation
papers
4 APPROPRIATE DIAGNOSIS 100%
IS MADE FOR A PEDIATIRC
PATIENT WITH MALARIA
4.1 Complications are identified Triangulate
correctly the history
4.2 Severity of the disease is and physical
deter- mined examination
findings
with the
diagnosis on
the admis-
sion history
sheet
5 APPROPRIATE TREATMENT 80%
IS PROVIDED FOR A PEDI-
ATIRC PATIENT WITH MA-
LARIA AT ADMISSION
5.1 Patient with high grade fever
Triangulate

1
is given antipyretics
order sheet
5.2 Antimalarial agents are used in with medi-
the right dose, route, frequency cation sheet
and duration as per the guideline
5.3 Transfusion is made for Triangu-
anemic patient late order
sheet with
transfusion
chart
5.4 Fluid resuscitation is given Triangulate
for hypovolemic shock order sheet

1
with medi-
cation sheet
5.5 Coma care is provided for
Order sheet
coma- tose patient
5.6 Anticonvulsant is administered Triangulate
for patient with seizure order sheet
with medi-
cation sheet
6 APPROPRIATE MONITORING 100%
IS DONE FOR A PEDIATIRC
PATIENT WITH MALARIA
DURING HOSPITAL STAY
6.1 Patient progress is evaluated Progress
at least daily sheet
6.2 Vital signs are monitored at
least QID
PR
RR Vital sign
sheet
Temperature
BP
SpO2 (oxygen saturation)
6.3 For patient with cerebral
Neurosign
malaria, GCS and seizure are
chart
followed at least QID
6.4 Post transfusion Hg measured Triangu-
for patient with severe late order
anemia who was transfused sheet with
investigation
paper
7 APPROPRIATE DISCHARGED 100%
WITH DISCHARGE CARE
IS PROVIDED FOR A PE-
DIATIRC PATIENT WITH
MALARIA
7.1 Clinical assessment is done to
confirm improvement before
discharge (vital signs are within
normal range, Hg has improved
for those who had severe
Discharge
anemia, Pt’s GCS is 15/15 for
summary
patient with cerebral malaria)
7.2 Advice is provided on
malaria preventive methods
7.3 Follow-up schedule is given
8 IDENTIFICATION OF PRO- 100%
VIDER IS DOCUMENTED
FOR A PEDIATIRC PATIENT
WITH MALARIA
8.1 Name and signature of the
physician is clearly documented History
on all admission history and P/E sheet
sheets
8.2 Name and Signature of the
Progress
phy- sician is clearly
note
documented on all progress
notes
8.3 Name and signature of the phy-
sician is clearly documented on Order sheet
all order sheets
8.4 Name and signature of the phy-
Discharge
sician is clearly documented on
sheet
discharge summary
8.5 Name and signature of the nurse
Medication
is clearly documented on all
sheet
medication sheets
9 PEDIATIRC PATIENT WITH 14%
MALARIA DIED WHILE
BEING TREATED IN THE
WARDS
Total standard met per chart
Percentage

1
References:
National Malaria guideline 2019
Audit Tool: HEI follow-up care
Facility name
Department/unit
Audit Topic HIV exposed infant follow-up care
Aim To improve the quality of follow-up care provided for HIV exposed infants

1
Objectives To ensure HIV exposed infants coming for follow-up are appropriately evaluated and diagnosed
To ensure HIV exposed infants coming for follow-up are appropriately investigated
To ensure HIV exposed infants coming for follow-up are appropriately treated
Period of Audit
Inclusion criteria HIV exposed infants coming for follow-up
Exclusion criteria (where applicable) HIV exposed infants who are less than six weeks of age, HIV exposed infants with other medical illness
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Actual Perfor-

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source and per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Remark
verification for- against
mance target
1 DEMOGRAPHIC AND IDEN- 100%
TIFICATION INFORMATION
IS RECORDED FOR HIV
EXPOSED INFANT DURING
FOLLOW UP

1.1 Infant’s name

1.2 Date of birth
1.3 Sex
1.4 Birth weight
1.5 Enrollment date
1.6 age at enrollment HIV exposed infant
1.7 ARV prophylaxis infant follow up chart
is taking
1.8 mother’s identification and
HIV status mentioned
1.9 Father’s identification, HIV
status mentioned
1.10 If mother/ father are HIV Posi-
tive ART status mentioned
1.11 Address (region, zone,
worked, kebele, [Link], [Link])
1.12 Maternal PMTCT intervention
is identified HIV exposed infant
1.13 Unique HIE ID number follow up chart
1.14 Infant card number
1.15 Infant’s source of referral
1.16 Follow up date of visit
1.17 Age during visit
2 APPROPRIATE FOLLOW UP 100%
HISTORY IS TAKEN FOR HIV
EXPOSED INFANT DURING
FOLLOW UP
2.1 Vaccination status for age
is assessed
2.2 Developmental milestones are
assessed
2.3 Infant feeding practice HIV exposed infant
is assessed follow up chart
2.4 Mothers breast condition is
assessed
2.5 CPT Adherence is assessed
and classified
3 APPROPRIATE PHYSICAL 100%
EXAMINATION IS PERE-
FORMED FOR HIV EXPOSED
INFANT DURING FOLLOW
UP
3.1 Anthropometry measurement
are taken
Weight HIV exposed infant
follow up chart
length
Head circumference

1
4 RELEVENT INVESTIGA- 100%
TIONS ARE DONE FOR HIV
EXPOSED INFANT DURING
FOLLOW UP
4.1 DNA PCR test is done at
an appropriate interval

DNA PCR test is done at

six weeks
Triangulate the age
DNA PCR test is done at of the infant with the

1
10week or 14week or DNA PCR test status
5monnths or six months if it on previous follow
was not determined at six up visits on the HIV
weeks or previous follow up exposed infant
visit follow up chart
DNA PCR is test is done for
an infant aged between 9-12
month who never had a DNA
PCR test done before

4.2 Rapid antibody test is done Triangulate the age

at an appropriate interval of the infant with the
Rapid antibody test is done DNA PCR test status
before DNA PCR test is done, on previous follow
for an infant aged between 9- up visits with the
12 month who never had a rapid antibody test
DNA PCR test done before status on the HIV
exposed infant
follow up chart
Rapid antibody test is done Triangulate the age
for an infant aged between of the infant with the
12month and 18month at least breast feeding status
six weeks after cessation of of the infant with
breast feeding the rapid antibody
test status on the
HIV exposed infant
follow-up chart
5 APPROPRIATE DIAGNOSIS 100%
( INCLUDING ASSOCIATED
FINDINGS) IS MADEFOR
HIV EXPOSED INFANT
DURING FOLLOW UP
5.1 Growth pattern is correctly Triangulate the
identified anthropometric
measurement results
with the identified
growth pattern on
the HEI Chart
5.2 Presence of reflags regarding
developmental milestones are
identified HIV exposed infant
5.3 Abnormal findings that may follow up chart
suggest HIV infection appro-
priately diagnosed
5.4 Appropriate conclusion based Triangulate the
on HIV TEST result is made test result with the
conclusion section
on the HIV exposed
infant follow up chart
6 APPROPRIATE TREATMENT 100%
IS PROVIDED FOR HIV
EXPOSED INFANT DURING
FOLLOW UP
6.1 Additional identified problems Triangulate the
including OI s are managed abnormal finding/di-
agnosis section with
treatment section
on the HIV exposed
infant follow up chart
6.2 Cotrimoxazole preventive Triangulate the
therapy is continued until HIV month of visit with
is excluded the scheduled date on
6.3 Appropriate follow up appoint- HIV exposed infant
ment is given to the patient (as follow up chart with
per the recommended timeline) recommended follow
up schedule
Total standards met per chart
Percentage

References:
National PMTCT Guideline
National Comprehensive HIV Care 2018

1
Audit Tool: [Link] follow-up care
Facility name
Department/unit
Audit Topic HIV/AIDS follow up care (pediatric patients)
Aim To improve the quality of follow-up care provided for HIV positive pediatric patients

1
Objectives To ensure pediatric patients with HIV/AIDS coming for routine care are appropriately evaluated
To ensure pediatric patients with HIV/AIDS coming for routine care are appropriately investigated
To ensure pediatric patients with HIV/AIDS coming for routine care are appropriately treated
Period of Audit
Inclusion criteria Pediatric HIV/AIDS patients who have been on follow-up for the past one year
Exclusion criteria (where applicable) Pediatric HIV/AIDS patients with other medical illness
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individ- ual patient
Actual Perfor-
Data Source

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- Remark
for- against
tion
mance target
1 DEMOGRAPHIC AND 100%
IDENTIFICATION INFORMA-
TION IS RECORDED FOR A
KNOWN PEDIATRIC HIV PA-
TIENT DURING FOLLOW-UP
1.1 Name
1.2 Sex
1.3 Age
1.4 MRN
1.5 Address(region, zone,
woreda, kebele, [Link], [Link]) HIV care/
1.6 Contact information ART fol-
1.7 Unique ART number low-up form
1.8 ART start Date
1.9 Date confirmed HIV positive
1.10 Type of HIV test done
1.11 Follow up date of visit
2 APPROPRIATE FOLLOW-UP 100%
HISTORY IS TAKEN FOR A
KNOWN PEDIATRIC HIV PA-
TIENT DURING FOLLOW-UP
2.1 Months on ART ( duration) is
identified
2.2 Symptoms of TB and TB HIV care/
risk factors are sought ART fol-
(labeled as P/N) low-up form

2.3 Presence of Pain is assessed

2.4 If the patient is on ART, Triangulate
drug adherence is assessed the specified
2.5 If the patient is on ART, drug dispen-
drug side effect is assessed sion section
with the
2.6 If the patient is on TPT,
adherence and
drug adherence is assessed
side effect sec-
2.7 If the patient is on TPT, tion on HIV
drug side-effect is assessed care/ART
2.8 If patient is on CPT, drug follow-up
adher- ence is assessed form
2.9 For patient with poor adherence, Triangulate
reason is identified the result on
the adherence
section with
reason section
on HIV care/
ART fol-
low-up form
2.10 Developmental milestones are HIV care/
assessed ART fol-
2.11 Disclosure status is assessed low-up form
3 APPROPRIATE PHYSICAL 100%
EXAMINATION IS PER-
FORMED FOR A KNOWN
PEDIATRIC HIV PATIENT
DURING FOLLOW-UP

1
3.1 Functional Status is assessed
(Ambulatory Working, Bedrid-
den)
3.2 Anthropometry measurements
are taken and interpreted Anthropom-
etry section
Weight
of HIV care/

1
Presence of edema ART fol-
length/height low-up form
Head circumference for children
less than three years
BMI for age for age >5yrs)
4 RELEVANT INVESTIGATIONS 80%
ARE DONE FOR A KNOWN
PEDIATRIC HIV PATIENT
DURING FOLLOW-UP
4.1 Gene Xpert is done, if Triangulate
TB screening is positive the result on
the TB
screen- ing
section with
the xpert
result section
on the HIV
care/ART fol-
low-up form
4.2 Viral load testing is done at 6th Triangulate
months, 12th months and yearly the month on
afterwards ART section
with the VL
result section
on the HIV
care/ART fol-
low-up form
4.3 AST/ALT, Hg and Creatine are Triangulate
measured, if drug side effect is the findings
identified on the drug
side effect
section with
the AST/ALT,
Hg and Cr
result section
on the HIV
care/ART fol-
low-up form
4.4 CrAg test is done for a Triangulate
patient with CD4<100 the CD4 result
with CrAg
investigation
paper
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A KNOWN PEDI-
ATRIC HIV PATIENT DURING
FOLLOW-UP
5.1 WHO staging of the disease
is done HIV care/
5.2 OI s are appropriately diagnosed ART fol-
5.3 Developmental status is iden- low-up form
tified
6 APPROPRIATE TREATMENT 100%
IS PROVIDED FOR A
KNOWN PEDIATRIC HIV
PATIENT DURING FOLLOW-
UP
6.1 Correct regiment of ARV Triangulate
drugs are dispensed the identified
WHO stage at
the front with
the dispensing
dose section
at the back
of the HIV
care/ART fol-
low-up form
6.2 If ART regiment is changed Triangulate
rea- son for change is described the identified
WHO stage at
the front with
the regiment
code section
at the back
of the HIV
care/ART fol-
low-up form

1
6.3 If the VL result is high Triangulate
enhanced adherence counseling the adher-
(EAC) is provided ence section
on the HIV
care/ART fol-
low-up form
with EAC

1
register
6.4 Appropriate TB treatment/ Triangulate
prophylaxis is given for the TB
patient with indications screen- ing
(Screening is negative and no result with the
contraindica- tions for IPT) TB treat-
ment /prophy-
laxis section
on the HIV
care/ART fol-
low-up form
6.5 Pain management is provided HIV care/
for patient with pain ART fol-
low-up form
6.6 CPT is dispensed for all under Triangulate
5 patients and For those above the age, iden-
5 tified WHO
with CD4 < 350 or WHO stage stage and
3 or 4 irrespective of CD4 count CD4 count of
the patient
with the CPT
sec- tion on
HIV care
follow-up
form
6.7 Fluconazole preventive therapy Triangulate
is provided for a patient with the CrAg
positive serum CrAg but result with the
asymp- tomatic for meningitis fluconazole
preventive
therapy
section on
the HIV care/
ART fol-
low-up form
6.8 Appropriate medications are Triangulate
provided for OI s, or HIV the OI/HIV
related cancers and other co related can-
morbidities cers section
with other
medication
or nutritional
supplements
dispensed
section on the
HIV fol-
low-up form

6.9 Appropriate nutritional supple- Triangulate

ments are provided for patient the Anthro-
with malnutrition pometry
section
with other
medication
or nutritional
supplements
dispensed
section on the
HIV fol-
low-up form

6.10 Follow-up schedule is given HIV care/

to the patient ART fol-
low-up form
7 A KKNOWN PEDIATRIC HIV 95%
PATIENT’S VIRAL LOAD IS
SUPPRESSED BELOW 1000
COPIES/ ML IN THE PAST 12
MONTHS
Total standards met per chart
Percentage

References:
National Comprehensive HIV Care guideline 2018

1
Communicable Diseases Audit Tools
Audit Tool: Pneumonia
Facility name
Department/unit
Audit Topic Management of pneumonia patients admitted to hospital

1
Aim To improve the quality of care provided for patients diagnosed with community acquired pneumonia.
To ensure adult patients diagnosed and admitted to ED then ward with community acquired pneumonia are appropriate-
ly evaluated
To ensure adult patients diagnosed and admitted to ED then ward with community acquired pneumonia are appropriate-
ly investigated
To ensure adult patients diagnosed and admitted to ED then ward with community acquired pneumonia are appropriate-
Objectives ly treated
To ensure adult patients diagnosed and admitted to ED then ward with community acquired pneumonia are appropriate-
ly monitored
To ensure adult patients diagnosed and admitted to ED then ward with community acquired pneumonia receive appro-
priate discharge care
Period of Audit
Inclusion criteria Adult patients ( age>14 years) diagnosed with community acquired pneumonia that required hospital admission
Exclusion criteria (where applicable) Children under age of 14yrs, Patient admitted with the diagnosis of health care associated pneumonia, Patient admitted
with the diagnosis of aspiration pneumonia
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
For the monitoring section, use data from the first seven days of patient’s admission
Actual Perfor-
Data Source

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance
chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- Remark
for- against
tion
mance target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
WITH COMMUNITY ACQUIRED
PNEUMONIA
1.1 Name of patient
1.2 Age
1.3 Sex ED Admis-
sion history
1.4 Date of admission
sheet
1.5 Time of admission
1.6 MRN
2 APPROPRIATE HISTORY IS TAKEN 100%
FOR A PATIENT WITH COMMU-
NITY ACQUIRED PNEUMONIA
2.1 Core symptoms are assessed and
characterized: Cough–whether it is
productive or not , color and con-
sistency of the sputum if productive,
Presence or absence of dyspnoea,
Wheeze, Haemoptysis, Pleuritic
pain, Fever and confusion
2.2 Risk factors for resistant pathogen
are assessed
Assessed for recent hospitalization
(last 90 days) and treatment with
broad spectrum antibiotics (third or ED Admis-
higher generation cephalosporins, sion history
quinolones, and carbapenems) for at sheet
least 5 days (both required)
2.3 Risk factors for pneumonia
are assessed
Presence of chronic lung conditions
(bronchoectasis, COPD)/known
medical condition( , DM, HTN,
CKD, CLD, malignancy
etc.)/immuno compromised state
(HIV, chemother- apy,
transplant)/history of cigarette
smoking, excessive alcohol intake
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
PATIENT WITH COMMUNITY
ACQUIRED PNEUMONIA
3.1 Vital sign are measured
BP ED Admis-
PR sion history
sheet and
RR
vital sign
Temperature sheet

1
SpO2
3.2 Sign of respiratory distress looked
for(Grunting, Nose flaring, use of ED History
accessory respiratory muscles, Body sheet
position)
3.3 Chest examination is done(shape,
movement, percussion note, air entry,
added sound, wheeze, BBS etc.),
pres- ence of clubbing checked
ED History
3.4 Cardiac examination is performed sheet
(heart sounds are auscultated, mur-
mur, JVP measured)

1
3.5 GCS is determined
4 RELEVANT INVESTIGATIONS 80%
ARE DONE FOR A PATIENT WITH
COMMUNITY ACQUIRED PNEU-
MONIA
4.1 CBC
4.2 Organ function tests (BUN, creati-
nine, AST, ALT, ALP)
4.3 Blood sugar(random or fasting)
Triangulate
4.4 Sputum culture and gram staining ED order
4.5 Blood culture (with in 24hrs, sheet with
before initiation of antibiotics) investigation
(except for primary hospitals) papers/sheet
4.6 CXR taken and time is documented
4.7 ESR
4.8 COVID 19 antigen or PCR
5 APPROPRIATE DIAGNOSIS OF 80%
COMMUNITY ACQIRED PNEU-
MONIA IS MADE FOR A PATIENT
WITH COMMUNITY ACQUIRED
PNEUMONIA
5.1 Diagnosis is reached based on clini- Triangulate
cal(history and physical examination) the history
and imaging finding of pneumonia and physical
5.2 Classification of Severity of examination
pneumo- nia is made using CURB65 findings with
the diagnosis
5.3 Additional co morbidities identified on the ED
and documented history sheet
6 APPROPRIATE TREATMENT IS 80%
PROVIDED FOR A PATIENT
WITH COMMUNITY ACQUIRED
PNEU- MONIA
6.1 Proper disposition of patient was done
using CURB 65 to either inpatient or
ICU setting
Patient with CURB 65 score of 2 ED order
is admitted to ward sheet

Patient with CURB 65 score of

three and above is admitted to ICU
6.2 Guideline concordant antibiotic treat-
ment is provided
Immediate appropriate empirical anti-
biotic therapy is initiated for
clinically unstable patients (
Respiratory failure, septic shock)
Antibiotics is started after diagnosis
is confirmed using imaging modality
in clinically stable patients
Triangulate
Antibiotics started for patient without ED order
risk factor for resistant pathogen with sheet with
a combination therapy with B lactum medication
(ampicillin + sulbactam , cefotaxime , sheet
ceftriaxone ) and macrolide ( (azithro-
mycin or clarithromycin) .
Antibiotics started for patient with
risk factor for resistant pathogen with
a combination therapy with vancomy-
cin or linezolid + piperacillin-tazo-
bactam or
cefepime or ceftazidime or meropen-
em or imipenem
Antibiotics is given for 5 - 7days who
became clinically stable patients (
sta- ble vital signs and normal
mentation ) with no complication Triangulate
ward order
Longer duration of antibiotics is sheet with
given for pneumonia patient who ward medica-
devel- oped complications such as tion sheet
abscess, empyema or necrotizing
pneumonia, meningitis, endocarditis,

1
other deep seated infection
Antibiotics is changed to oral Triangulate
therapy in a patient who became ward order
hemody- namically stable and sheet with
showed clinical improvement , and ward medica-
able to ingest and absorb oral tion sheet
medications
7 APPROPRIATE MONITORING 100%

1
IS DONE FOR A PATIENT
WITH
COMMUNITY ACQUIRED
PNEU- MONIA
7.1 Vital sign are followed at least Triangulate
every six hour ward order
sheet with
vital sign
sheet
7.2 Patient progress is assessed by a Ward pro-
physi- cian at least daily gress note
7.3 For patient showing no improvement Triangulate
or deteriorating, further investigation ward progress
is sought note with
order sheet
with investi-
gation sheet
7.4 Patient showing no improvement Triangu-
or deterioration after 48 hours of late the
initiation of antibiotics is evaluated assessment
by senior physicians or referred on Ward
progress note
with decision
taken on
referral
8 APPROPRIATE DISCHARGE CARE 100%
IS PROVIDED FOR A PATIENT
WITH COMMUNITY ACQUIRED
PNEUMONIA
8.1 Vital signs measure in the 24
hours prior to discharge Triangulate
BP the date of
PR discharge
with Ward
RR
Vital sign
Temperature sheet
SpO2
8.2 Proper advice given to the patient
Dietary uptake
Physical activity
When to visit hospital Discharge
summary
What medications to be taken at sheet
home
8.3 Follow up schedule given to
the patient
9 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR A PATIENT
WITH COMMUNITY ACQUIRED
PNEUMONIA
9.1 Name and signature of the physician
is clearly documented on admission History sheet
history and P/E sheets
9.2 Name and Signature of the
Progress
physician is clearly documented on
note/sheet
all progress notes
9.3 Name and signature of the physician
is clearly documented on all order Order sheet
sheets
9.4 Name and signature of the nurse is
Medication
clearly documented on all medication
sheet
sheets
9.5 Name and signature of the physician Discharge
is clearly documented on discharge summary
summary sheet sheet
10 PATIENT ADMITTED WITH THE 10%
DIAGNOSIS OF CAP DIED WHILE
BEING TREATED IN THE HOSPI-
TAL
Total standards met per chart
Percentage

References:
South African Community acquired pneumonia Treatment

1
Guideline
American Thoracic society Pneumonia Treatment
Guideline 2019
Audit Tool: TB Initial care
Facility name
Department/unit
Audit Topic TB initial care
Aim To improve the quality of care provided for adult patients with the diagnosis of TB

1
Objectives To ensure adult patients diagnosed with TB are evaluated appropriately
To ensure adult patients diagnosed with TB are investigated appropriately
To ensure adult patients diagnosed with TB are treated appropriately
To ensure adult patients diagnosed with TB are counseled appropriately
To ensure adult patients with TB who have indication are referred appropriately
Period of Audit
Inclusion criteria Adult patients newly diagnosed with TB within the audit period
Exclusion criteria (where applicable) Patient diagnosed with MDR TB, Pt who took anti TB treatment > 1month ,Children under Age <15
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Data Perfor-
Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Source mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
perfor-
Target

No Standards/criteria Remark
and verifi- against
mance
cation target
1 DEMOGRAPHIC AND IDENTI- 100%
FICATION INFORMATION IS
RECORDED FOR PATIENT A
WITH TUBERCULOSIS
1.1 Name of the patient
1.2 Age
1.3 Sex
1.4 Address of patient ([Link],
city, woreda, kebele)
History
1.5 Date of visit sheet
1.6 MRN
1.7 Name of patient’s contact person
1.8 Address of patient’s contact
person ([Link], city, woreda,
kebele)
2 APPROPRIATE HISTORY IS 100%
TAKEN FOR A PATIENT WITH
TUBERCULOSIS
2.1 Core symptoms are identified and
characterized: Cough-–whether it is
productive or not, color and con-
sistency of the sputum if
productive, Fever, Night sweats,
Loss of appetite, weight loss
2.2 Presence of close contact
with known TB patient or
chronic cougher is assessed
2.3 Presence of chrnonic medical con-
dition (HIV, CLD, CKD, ) is assesed
2.4 Pregnancy status for a female
pa- tient is asked
2.5 Previous history of TB treatment
is aseesed
2.6 For a patient with previous
history of TB treatment details of
the inci- dence are sought
How the previous TB diagnosis
History
is reached
sheet
Time and duration of treatment
Out come of treatment
2.7 Symptoms for extra-pulmonary
TB are assessed
Pleuritic chest pain and shortness
of breath
Headache, Fever, confusion,
photo- phobia
Back pain and swelling
Retrosternal cheastpain
Body weakness, abnormal
body movement
Abdominal pain, Abdominal
swelling
Neck swelling (Adrenal TB )
Hyper pigmentation

1
3 APPROPRIATE PHYSICAL 100%
EXAMINATION IS PERFORMED
FOR PATIENT A WITH TUBER-
CULOSIS
3.1 Vital sign are taken
BP
PR
RR
Temperature

1
Spo2
3.2 Antropometric measurements are
done
Wt
Height
BMI
3.3 Lymph nodes are assessed for Lym- History
phadinopaty and scrofula sheet
3.4 Chest is examined for decreased
chest movement, stony dullness
on percussion, absent air entry,
added and transmitted sounds
3.5 CVS is examined for raised JVP
and distant heart sounds
3.6 Abdomen examined for Hepa-
to-spleenomegally and ascites
3.7 Vertebrae is examined for Gibbus
3.8 Presence of meningial signs
is assessed
4 RELEVANT INVESTIGATIGA- 80%
TIONS ARE DONE FOR PATIENT
A WITH TUBERCULOSIS
4.1 CBC Triangu-
4.2 ESR late the
plan on
4.3 Organ function test (liver enzymes, the histo-
serum bilirubin,creatinine,BUN) ry sheet
with the
investi-
gation
papers
4.4 Bacteriological diagnostic tests for
tuberculosis are done
Xpert MTB assay is used as an
initial diagnostic test from the site
of TB (from sputum, CSF, pleural,
peritoneal, synovial fluids and other
body tissue aspirates) (for gene
Xpert site facility)
Smear Microscopy done from the
site TB (from sputum, CSF, pleural,
peritoneal, synovial fluids and other
body tissue aspirates) and bacilli
load reported as: No AFB Seen,
positive Scanty, +, ++, +++ (for
facilities that are not gene xpert site) Triangu-
Specimen sample is sent for Gene late the
Xpert assay for patient whose initial diagnosis
smear microscopy result is positive on the
history
Urine LF-LAM assay is done for sheet with
diagnosis of active TB in HIV-pos- the inves-
itive adult, with advanced HIV tigation
disease or who is seriously ill, or paper
with a CD4 cell count of less than
200 cells/mm3
FL-LPAs (first line probe assay) is
done for MDR TB suspect (contact
with a known MDR person, patient
living in a high MDR prevalent
setting
First Line DST (drug susceptibility
test) is done for patient with prior
TB treatment history for one or
more month or contact history with
RR/MDR-TB or is from health care
settings or congregated settings or
other known high MDR-TB preva-
lent settings

1
4.5 CXR is taken
4.6 Histo-Pathological Examination
Trian-
is done for the diagnosis of
gulate
extra pulmonary TB
investiga-
Fine needle aspiration from ac- tion plan
cessible mass (except for on history

1
primary hospital sheet with
Tissue biopsy from any body radiology
tissues (except for primary investiga-
hospital) tion paper
Aspiration of effusions from
serous membranes
4.7 HIV testing done HIV test
form or
on inside
part of
cover page
of card
5 APPRORIATE DIAGNOSIS IS 100%
MADE FOR A PATIENT
WITH TUBERCULOSIS
5.1 Drug sensitivity status is
identified (drug-sensitive TB,
rifampicin-re- sistant TB(RR-
TB), Multi drug resistant TB
(MDR-TB) Triangu-
5.2 Appropriate classification is made late the
based on approach used for diag- history,
nosis :presumptive TB diagnosis physical
or bacteriologically confirmed examina-
TB, clinically diagnosed TB case tion and
5.3 Correct classification is made lab inves-
based on anatomical site of tigation
occurrence: Pulmonary TB or findings
Extra Pulmonary TB with the
diagnosis
5.4 Correct classification is made on the
based on history of previous history
treatment (New or Relapse or sheet
Treatment after Failure or
Treatment after loss to follow-up
,defaulter)
5.5 Co-morbid conditions like preg-
nancy, renal or liver disease are
correctly identified
6 APPROPRIATE TREATMENT 100%
IS PROVIDED FOR PATIENT A
WITH TUBERCULOSIS
6.1 Pre-treatment assessment is done History
Appropriate treatment supporter is sheet and
identified unit TB
Contact screening is done register
6.2 2(RHZE)/4RH is started for new Triangu-
patient with confirmed susceptibili- late the
ty to Rifampicin diagnosis
on the
history
sheet with
investiga-
tion paper
with the
medi-
cation
section
on the
unit TB
register

6.3 For new patient whose baseline Triangu-

Xpert MTB RIF test is late his-
unknown, but Low DR-TB Risk tory and ,
Group diagnosis
,2(RHZE)/4RH is started and rapid on the
DST is sent history
sheet with
medi-
cation
section on
unit TB
register
and inves-
tigation
paper

1
Triangu-
late his-
tory and
diagnosis
on history
For new patient whose baseline sheet with
Xpert MTB RIF test is unknown investi-

1
and known/ presumed contact gation on
6.4 with DR-TB case, rapid DST is investiga-
done before initiation of anti- tion paper
TB drugs with med-
ication
section on
unit TB
register

Trian-
gulate
diagnosis
on history
Patient with a diagnosis of relapse sheet with
or treatment after Loss to follow up, investi-
or treatment failure or other previ- gation on
6.5 ously treated,2 (RHZE) / 4(RH) is investiga-
initiated; and DST for RIF and tion paper
INH is determined with med-
ication
section on
unit TB
register

Trian-
gulate
investiga-
tion result
If either RR/MDR-TB or Hr-TB on the
(DST result shows resistance to investiga-
6.6 either Rifampicin or INH or both)- tion paper
patient is sent to MDR TB center with
column
no,80 on
unit TB
register
Trian-
gulate
weight
registered
on the
unit TB
Drugs are dispensed based on body register
6.7 with the
weight
medi-
cation
provided
with the
national
guideline

6.8 Adjuvant Corticosteroid Therapy

is provided for patient with TB
meningitis and/or pericarditis for
6-8 weeks
6.9 Pyridoxine (vit B6) is supplemented Unit TB
register
6.10 Directly Observed Treatment pro-
vided (for all intensive phase)
6.11 Daily appointment is given to
the patient
7 APPROPRIATE REFERRAL IS 100%
MADE TO A HIGHER LEVEL
INSTITIUTION FOR A
PATIENT WITH
TUBERCULOSIS WITH
INDICATION (FOR PRIMARY
HOSPITAL AND FACILITIES
WHICH DOESNOT HAVE TB
CLINIC)
7.1 Patient whose initial evaluation,
workup and diagnosis of TB is
TB refer-
made in a facility that does not have
ral form
TB clinic is referred to catchment
facili- ty that provides the service
7.2 Patient with EPTB is referred to Trian-
higher level institution for gulate

1
FNAc (for primary hospitals) diagnosis
on history
sheet with
referral
paper
7.3 Patient with a diagnosis of relapse Trian-
or treatment after Loss to follow gulate
up, or treatment failure or other diagnosis
previ- ously treated in whom on history
RR/MDR- TB or Hr-TB (DST sheet with
result shows resistance to either investiga-
Rifampicin or INH or both)- is tion re-

1
referred to MDR TB treatment sults with
center referral
paper and
unit TB
registry

7.4 Patient with CLD , CKD is Trian-

referred after anti-TB is initiated gulate
(only for primary hospitals) diagnosis
on history
sheet with
referral
paper
8 PROPER COUNSELING IS PRO- 100%
VIDED FOR A PATIENT WITH
TUBERCULOSIS
8.1 Counseling on TB drugs
Sideffects is provided
8.2 Counseling on drug adherence is
provided
8.3 Counseling and education on HIV/ History
AIDS and prevention of HIV trans- sheet and
mission is provided unit TB
8.4 Nutritional counseling is given registry
8.5 Adherence counseling for support-
er is provided
8.6 Pt is counseled about when to
return
9 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR PATIENT
A WITH TUBERCULOSIS
9.1 Name and signature of the phy-
History
sician is clearly documented on
sheet
history and P/E sheet
9.2 Name and signature of the phy-
Referral
sician is clearly documented on
paper
referral paper
Total Standards met per chart
Percentage

References:
Guidelines for Clinical and Programmatic Management of TB, TB/HIV, DR-TB and Leprosy in
Ethiopia 2021

1
Audit Tool: TB Follow-up care
Facility name
Department/unit
Audit Topic TB follow-up care
Aim To improve the quality of clinical care provided for patients with tuberculosis who are on follow-up

1
Objectives To ensure adult patients with tuberculosis who are on follow-up are evaluated appropriately
To ensure adult patients with tuberculosis who are on follow-up are investigated appropriately
To ensure adult patients with tuberculosis who are on follow-up are treated appropriately
To ensure proper counseling is provided for patients with tuberculosis who are on follow-up
To ensure adult patients with tuberculosis who are on follow-up and have indication are referred appropriately
Period of Audit
Inclusion criteria Adult patients with TB who are on follow-up within the audit period
Exclusion criteria (where applicable) Newly diagnosed TB patients, Pt diagnosed with MDR TB, Children under Age <15
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Use the weekly data from the patient’s continuation phase care (end of second month until end of sixth month) The
patient is expected to be evaluated weekly by the provider in this phase
Actual Perfor-
Data

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Source and Remark
for- against
verification
mance target
1 DEMOGRAPHIC AND IDENTIFICA- 100%
TION INFORMATION IS RECORDED
FOR A PATIENT WITH TUBERCULO-
SIS DURING FOLLOW-UP
1.1 Name of patient
1.2 Age
1.3 Sex
1.4 Address of patient
Follow-up
1.5 Date of visit sheet
1.6 MRN
1.7 Name of contact person
1.8 Address of contact person
2 APPROPRIATE FOLLOW UP HISTORY 100%
IS TAKEN FOR A PATIENT WITH TU-
BERCULOSIS DURING FOLLOW-UP
2.1 Persistence or reappearance of clinical
feature of TB (cough, fever, night
sweat- ing…) is assessed
2.2 Occurrence of Adverse drug reaction Follow-up
(skin rash, joint pain, loss of color sheet
vision, nausea, vomiting, jaundice, foot
burning sensation…) are assessed
2.3 Treatment adherence is assessed
2.4 Presence of substance use/abuse is Triangu-
as- sessed, if adherence is poor late the
adherence
on unit TB
register
phase with
follow up
sheet
2.5 Development of TB complications(
joint and back pain and deformity,
headache, change in behavior, extremity
weakness, shortness of breath…) are Follow-up
assessed sheet
2.6 For a woman in reproductive age group
Family planning -contraception needs are
assessed
3 APPROPRIATE FOLLOW UP PHYSI- 100%
CAL EXAMINATION IS DONE FOR
A PATIENT WITH TUBERCULOSIS
DURING FOLLOW-UP
3.1 General appearance and body built is
assessed
3.2 Vital sign are measured
BP
Follow-up
PR sheet
RR
Temperature
Spo2
3.3 Weight is measured Follow up

1
sheet and
unit TB
register
3.4 Color of the conjunctiva is assessed
3.5 Presence of loss of color vision is assessed
3.6 Chest is examined for decreased chest
movement, stony dullness on
percussion, absent air entry, added and
transmitted sounds Follow-up

1
sheet
3.7 CVS is examined for raised JVP
and distant heart sounds
3.8 Skin is assessed for lesions
3.9 Mental status and muscle power
are examined
4 RELEVANT FOLLW-UP LAB. IN- 80%
VESTIGATION ARE DONE FOR A
PATIENT WITH TUBERCULOSIS
DURING FOLLOW-UP
4.1 Liver enzymes and bilirubin levels were Triangu-
determined for a patient with a suspected late drug
side effect side effect
symptoms
on history
with lab in-
vestigation
report
4.2 AFB microscopy is done at the
appropri- ate interval Investiga-
End of 2nd months tion papers
and unit
End of 5th months TB register
End of 6th months
4.3 Xpert MTB RIF and FL-LPA is done Triangulate
when AFB microscopy become the AFB
positive result with
Xpert MTB
RIF and
FL-LPA
result on
investiga-
tion papers
and unit
TB register
5 APPROPRIATE FOLLOW UP DIAG- 100%
NOSIS IS MADE FOR A PATIENT
WITH TUBERCULOSIS DURING
FOLLOW-UP
5.1 Clinical status is identified (improving, Triangulate
deteriorating) the history
5.2 Development of adverse drug event and phys-
is identified ical ex-
5.3 Treatment Adherence status is identified amination
findings
5.4 Presence of drug resistance is identified with the
5.5 TB related complications are identified diagnosis
5.6 For a patient who completed the treat- on the
ment, treatment outcome is determined( follow-up
Cured or completed or Treatment failure sheet/Unit
or lost to follow-up or Died or relapse) Tb register
6 APPROPRIATE FOLLOW UP TREAT- 100%
MENT IS PROVIDED FOR A PATIENT
WITH TUBERCULOSIS DURING
FOLLOW-UP
6.1 Anti-TB drugs are consumed by the Unit TB
patient under direct observed therapy register
6.2 Anti-TB drugs Drug dose adjustment is Triangulate
made based on weight band at the end of the weight
two month measured
at the end
of two
month
with the
drug dose
dispensed
at the be-
ginning of
continua-
tion phase
on the Unit
TB register

6.3 Pyridoxine (vit B6) is supplemented Unit TB

register

1
6.4 For non responding patient, MDR or Triangulate
alternative diagnosis considered the diag-
nosis with
plan on the
follow-up
sheet

1
6.5 Identified treatment adherence barriers Triangulate
are resolved the adher-
ence status
on the
diagnosis
with the
action tak-
en on the
follow-up
sheet
6.6 Identified drug advise events Triangulate
managed appropriately the identi-
fied drug
side effects
on the
diagnosis
with the
action tak-
en on the
follow-up
sheet

6.7 Identified TB complications are Triangu-

managed appropriately late the
identified
complica-
tions on
the diagno-
sis with the
action tak-
en on the
follow-up
sheet

6.8 Weekly appointment is given to Unit TB

the patient register
continua-
tion phase
section and
follow-up
sheet
7 APPROPRIATE REFERRAL IS MADE 100%
TO A HIGHER LEVEL INSTITIUTION
FOR A PATIENT WITH TUBERCU-
LOSIS WITH INDICATION DURING
FOLLOWUP (FOR PRIMARY HOSPI-
TAL AND FACILITIES WHICH DOES-
NOT HAVE TB CLINIC)
7.1 Patient with drug susceptibility test Triangulate
result showing resistance to either diagnosis
Rifampicin or INH or both is referred to on history
MDR TB treatment center sheet with
investi-
gation
results with
referral
paper and
unit TB
registry

7.2 Patient with CLD or CKD is referred af- Triangulate

ter anti-TB is initiated (only for primary diagnosis
hospitals) on follow
up sheet
with refer-
ral paper
8 IDENTIFICATION OF PROVIDER 100%
IS DOCUMENTED FOR PATIENT
A WITH TUBERCULOSIS DURING
FOLLOW-UP
8.1 Name and signature of the physician
Follow-up
is clearly documented on the
sheet
evaluation notes (follow up sheet)
8.2 Name and signature of the physician Referral
is clearly documented on referral sheet
paper
9 PATIENT TOOK ALL ANTI-TB MEDI- 100% Unit TB
CATION DOSES FULLY registry
(DOT
section)

1
Total standards met per chart
Percentage

References:
Guidelines for Clinical and Programmatic Management of TB, TB/HIV, DR-TB and Leprosy in Ethiopia
2021
Audit Tool: [Link] Initial care
Facility name
Department/unit
Audit Topic HIV/AIDS Adult patients Initial care
Aim To improve the quality of clinical care for newly diagnose HIV patients

1
Objectives To ensure newly diagnosed HIV patients are appropriately evaluated
To ensure newly diagnosed HIV patients are appropriately investigated
To ensure newly diagnosed HIV patients are appropriately treated
Period of Audit
Inclusion criteria Newly diagnosed HIV patients
Exclusion criteria (where applicable) HIV/AIDs patients who have been enrolled to ART care previously and initiated on treatment in another facility
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to
the individual patient
Actual Perfor-
Data
Target

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Source and Remark
for- against
verification
mance target
1 DEMOGRAPHIC AND
IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A NEWLY
DIAGNOSED HIV PATIENT
1.1 Name
History
1.2 Sex sheet and
1.3 Age Intake
1.4 MRN form
1.5 Marital Status
1.6 Occupation
1.7 Address (Region, Town, Sub-City, Kebele)
1.8 Telephone
1.9 Unique ART Number Intake
form
1.10 Unit TB number (for TB patient)
1.11 Enrollment date
1.12 Client’s contact person (care giver) full Infor-
mation (name , age, sex, relation, address)
2 RETESTING AND RECENCY TESTING IS
DONE FOR A NEWLY DIAGNOSED HIV 100%
PATIENT
2.1 Confirmed date of HIV positive (retesting) is Intake
documented form
2.2 Confirmed HIV positive patient is enrolled on
Register
the ART register
2.3 Recency testing is done HIV recen-
cy register
3 APPROPRIATE HISTORY IS TAKEN FOR A
100%
NEWLY DIAGNOSED HIV PATIENT
3.1 HIV related history is taken

Date and location confirmed HIV-positive Intake

form
Risk factors related to HIV accusation are History
identified sheet
Entry point into HIV care (PICT, VCT, Intake
ICT, Referral) identified form
3.2 Complete history of the client is taken
Presence of any HIV related illnesses in
the past
Symptom of TB, (Any cough, night
sweating, fever, contact Hx, Wt loss) History
Symptoms of Cryptococal meningitis sheet and
(head- ache, fever, neck stiffness, Intake
photophobia,) form
Symptoms of other OI, (Body weakness,
cough, shortness of breath, abdominal pain,
bloody diarrhea, skin lesions, decreased
urine output, generalized body swelling,
Chronic Diarrhea)
Symptoms of sexually transmitted illness
History
Co-morbidities, (DM, HTN, cardiac diseases,) sheet and
Intake
Pregnancy status form

1
Past and current medication and allergy
history
Presence of mental health problems
History of substance use
Immunization history is assessed History
sheet
3.3 Sexual history is assessed

1
Patient’s sexual practices is assessed
Symptoms of STI and history of prior STI are
assessed
HIV status of their partner is assessed History
Disclosure of HIV status to their partner is sheet and
assessed Intake
form/ICT
form
3.4 Family member HIV status is assessed Intake
form
4 APPROPRIATE PHYSICAL EXAMINATION
IS PERFORMED FOR A NEWLY DIAG- 100%
NOSED HIV PATIENT
4.1 Vital Signs are measured
BP
PR
RR
Temperature
4.2 Wt and height measured
4.3 BMI calculated
4.4 Functional status is assessed
(Ambulatory Working, Bedridden) History
sheet and
4.5 Nutritional screening result: is determined Intake
(Normal, Mild, Moderate, Sever Over Wt) form
4.6 Presence of oral thrush, oral ulcer, poor
dentations, Kerato conjunctivitis, oral hairy
leukoplakia, pale conjunctiva, yellowish
dis- coloration of the eye are assessed
4.7 Presence of generalized lymphadenopathy
is assessed
4.8 Presence of abdominal swelling,
hepato- spleeno megally is assessed
4.9 Presence of genital wart, genital ulcer
is assessed
4.12 Signs of Herpes Z, Kaposi sarcoma History
are assessed sheet and
Intake
4.13 Presence of gait abnormality, focal neurologic form
deficit, signs of dementia, memory impair-
ment, are assessed
4.14 Precervical counseling and linkage is made
for a female patient
Identification of the patient is recorded
(Name, Age, MRN, Unique ART
number)
Patient’s previous Cx Ca screening status
is assessed
Patient’s eligibility for Cx Ca screening is Pre-Cer-
assessed vical
counseling
The criteria that made the patient eligible and linkage
is identified form
Counseling is provided for eligible
patient prior to linkage
Eligible patient is either linked to Cx Ca
unit or given appointment for linkage
Eligible patient who is not linked to Cx
Ca unit is given appointment for linkage
and reason for not linking is identified
4.15 Cervical Ca screening is done for Cervical
female patient screening
Cervical Ca screening is done on the same day form/
or appointment date is given for screening Pre-Cer-
vical
Eligible patient who is not screened on the
counseling
same day is given appointment for
and linkage
screening and reason for not screening is
form
identified
5 RELEVANT INVESTIGATION ARE DONE
80%
FOR A NEWLY DIAGNOSED HIV PATIENT
5.1 Baseline CD4 count

1
5.2 Viral load
5.3 CBC Investiga-
tion papers
5.4 Organ function test ( LFT, RFT)
5.5 FBS/ Hg A1c
5.6 Lipid profile
5.7 Tests for hepatitis and spirochete Investiga-
infection (HBsAg , HCV Ab, VDRL ) tion papers
5.8 Pregnancy test and other tests as necessary
5.9 For patient with presumptive TB Triangulate
diagnosis, Gene Xpert/LF-LAM and CXR the history,
P/E and

1
diagnosis
with the
investiga-
tion
5.11 Creptococal screening (serum CRAg) Triangulate
for patient with CD4 <100 the CD4
result with
CrAg in-
vestigation
paper
6 APPROPRIATE DIAGNOSIS IS MADE FOR
100%
A NEWLY DIAGNOSED HIV PATIENT
6.1 Clinical staging is correctly done (see Triangu-
WHO HIV/ADIS clinical staging late the
guideline) history and
6.2 Opportunistic Infections are Identified P/E ,lab
findings
6.3 Co morbid illnesses are identified from histo-
with the
ry, P/E and investigations
diagnosis
on history
sheet/in-
take form

6.4 Eligibility for ART is determined Intake

form
7 APPROPRIATE TREATMENT IS STARTED
100%
FOR A NEWLY DIAGNOSED HIV PATIENT
7.1 Date of client readiness documented Triangulate
7.2 CPT is started (if indicated) the history,
P/E, lab
7.3 TPT is started (if clinically indicated) find-
7.4 OI’s are treated before ART initiation ings and
7.5 Fluconazole preventive therapy provided diagnosis
for a patient with positive serum CrAg but with the
asymptomatic treatment
provided
7.6 Appropriate 1st line ART drug started on history
accord- ing to the national guideline for a sheet and
patient who is ready (ART Drugs:- 1j; 1d; 1e; follow up
1g; 1k) form
7.7 A patient with Cervical Ca is managed/re- Triangulate
ferred the history,
P/E, lab
find-
7.8 Symptoms of pain assessed and managed ings and
(if indicated) diagnosis
with the
treatment
provided
7.9 Nutritional Supplement is provided for on history
SAM and MAM patient sheet and
follow up
form

7.10 ICT and treatment is provided

Identification of the index case is documented
Marital status of the index case is identified
Whether the index case has disclosed their
status to the partner is determined
Partner’s HIV status is identified
Index’s current status is assessed
Eligibility for partner and family based ICT is
determined based on the assessment
Partner and family based ICT is offered
ICT form
Acceptance of the offer is determined
Serial number is recorded if offer is accepted
Elicited contacts are identified and their de-
tails are recorded (Names, ages, sex,
relation)
Test method is agreed (Client,
contractual,, dual, provider)
Results are collected
PrEP is provided for the partner if the partner
is HIV negative
7.11 Appointment is given to the patient
Next appointment date documented in the History
chart sheet and

1
follow up
form
Next appointment date documented in the Registra-
registration tion book
8 PROPER COUNSELING IS PROVIDED FOR
100%
A NEWLY DIAGNOSED HIV PATIENT
8.1 Counseling and education on HIV/AIDS and
prevention of HIV transmission is provided
8.2 Counseling on ART and TPT drugs,
Side effects is provided

1
8.3 Counseling on ART/TPT/CPT adherence is History
provided sheet
8.4 Counseling for family planning is provided
8.5 Counseling on Status Disclosure is provided
8.6 Counseling of positive living, and safe
sexual practice is provided
9 APPROPRIATE REFERRAL TO HIGHER
HEALTH FACILITIES IS MADE FOR A
NEWLY DIAGNOSED HIV PATIENT WITH 100%
INDICATION (ONLY FOR PRIMARY HOS-
PITALS)
9.1 Patient with CLD , CKD is referred to Triangulate
higher health facility the history,
P/E, lab
findings,
and diag-
nosis on
the history
sheet with
referral
paper
10 IDENTIFICATION OF THE PROVIDER
IS DOCUMENTED FOR A NEWLY DIAG- 100%
NOSED HIV PATIENT
10.1 Name and signature of the physician is History
clearly documented on the evaluation notes sheet
Total standards met per chart
Percentage

References:

National Comprehensive HIV Care guideline 2018

Audit Tool: [Link] follow-up care
Facility name
Department/unit
Audit Topic HIV/AIDS adult patients follow-up care
Aim To improve the clinical care of patients with HIV who are on follow-up
Objectives To ensure adult patients with HIV who are on follow-up are appropriately evaluated
To ensure adult patients with HIV who are on follow-up are appropriately investigated
To ensure adult patients with HIV who are on follow-up are appropriately treated
Period of Audit
Inclusion criteria All adult patients diagnosed with HIV/AIDS and enrolled for chronic HIV care more than six month
Exclusion criteria (where applicable) HIV/AIDS patients who are pregnant and children
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Target Actual Perfor-

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Data Source and per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Remark
verification for- against
mance target
1 DEMOGRAPHIC AND 100%
IDENTIFICA- TION INFORMATION
IS RECORD- ED FOR A KNOWN
HIV PATIENT DURING
FOLLOWUP
1.1 Name
1.2 Sex
1.3 Age
1.4 MRN
1.5 Address
HIV care/ART
1.6 Telephone follow-up form
1.7 Contact information
1.8 Unique ART number
1.9 ART start Date
1.10 Follow up date

1
2 APPROPRIATE FOLLOW-UP HISTO- 100%
RY IS TAKEN FOR A KNOWN HIV
PATIENT DURING FOLLOWUP
2.1 Months on ART ( duration) is assessed
2.2 Symptoms of TB and TB risk HIV care/ART
factors (labeled as P/N) are follow-up form
assessed
2.3 Presence of pain is assessed
2.4 If the patient is on ART, drug

1
adherence is assessed
Triangulate the
2.5 If the patient is on ART, drug side specified drug
effect is assessed dispensing sec-
2.6 If the patient is on TPT, drug tion with the ad-
adherence is assessed herence and side
2.7 If the patient is on TPT, drug side effect section on
effects is assessed HIV care/ART
follow-up form
2.8 If patient is on CPT, drug adherence is
assessed
2.9 For patient with poor adherence reason Triangulate
is identified the result on
the adherence
section with
reason section
on HIV care/
ART follow-up
form
2.10 Pregnancy status, FP and HIV care/ART
contraceptive methods are assessed follow-up form
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
KNOWN HIV PATIENT DURING
FOLLOWUP
3.1 Anthropometric measurements are done
Weight
Anthropometry
Presence of edema section of HIV
BMI care/ART fol-
low-up form
MUAC for pregnant woman or
bed ridden patient
3.2 Functional Status is assessed
(Ambulato- ry Working, Bedridden)
3.3 Precervical counseling and linkage
is made for a female patient
Identification of the patient is record-
ed (Name, Age, MRN, Unique ART
number)
Patient’s previous Cx Ca screening
status is assessed
Patient’s eligibility for Cx Ca screening
is assessed
The criteria that made the patient
eligi- ble is identified
Counseling is provided for Anthropometry
eligible patient prior to linkage section of HIV
care/ART fol-
Eligible patient is either linked to Cx
low-up form
Ca unit or given appointment for
linkage
Eligible patient who is not linked to Cx
Ca unit is given appointment for
linkage and reason for not linking is
identified
3.4 Cervical Ca screening is done for
female patient
Cervical Ca screening is done on the
same day or appointment date is
given for screening
Eligible patient who is not screened
on the same day is given appointment
for screening and reason for not
screening is identified
4 RELEVANT FOLLOW-UP INVES- 80%
TIGATIONS ARE DONE FOR A
KNOWN HIV PATIENT
DURING FOLLOWUP
4.1 Viral load testing is done at 6th Triangulate the
months, 12th months after initiation month on ART

1
and then after yearly section with
the VL result
section on the
HIV care/ART
follow-up form
4.2 CrAg test is done for a patient Triangulate the
with CD4<100 CD4 result
with CrAg
result on
investigation
paper
4.3 AST/ALT, Hg and Cr if drug side effect Triangulate the

1
is identified findings on the
drug side effect
section with the
AST/ALT, Hg
and Cr result
section on the
HIV care/ART
follow-up form
4.4 Gene Xpert is done if TB screening Triangulate the
is positive result on the
TB screening
section with
the xpert result
section on the
HIV care/ART
follow-up form
4.5 Pregnancy test is done for woman of Triangulate
child bearing age not receiving the pregnancy
family planning status/FP meth-
od section on
the HIV care/
ART follow-up
form with the
investigation
paper (urine
HCG test) in the
patient folder
5 APPROPRIATE DIAGNOSIS IS MADE 100%
FOR A KNOWN HIV PATIENT
DURING FOLLOWUP
5.1 WHO stage of the disease is determined
5.2 OI s are appropriately diagnosed ART follow up
form/ history
5.3 Nutritional abnormalities are correctly sheet
identified
6 APPROPRIATE TREATMENT IS 100%
PROVIDED FOR A KNOWN
HIV PATIENT DURING
FOLLOWUP
6.1 Correct regiment of ARVdrugs Triangulate
are dispensed the identified
WHO stage at
the front with
the dispensing
dose section at
the back of
the HIV
care/ART
follow-up form
6.2 If ART regiment is changed reason Triangulate
for change is described the identified
WHO stage at
the front with
the regiment
code section
at the back of
the HIV
care/ART
follow-up form
6.3 If the VL result is high enhanced Triangulate
adher- ence counseling (EAC) is the adherence
provided section on
the HIV care/
ART follow-up
form with EAC
registry
6.4 Appropriate TB treatment/prophylaxis Triangulate the
is given for patient with indications TB screening
result with the
TB treatment
/prophylaxis
section on the
HIV care/ART
follow-up form
6.5 CPT is dispensed for patient whose Triangulate
CD4 < 350 or WHO stage 3 or 4 the identified
irre- spective of CD4 count WHO stage and
CD4 count of
the patient with

1
the CPT section
on HIV care
follow-up form
6.6 Pain management is provided for patient HIV care/ART
with pain follow-up form
6.7 Fluconazole preventive therapy is pro- Triangulate the
vided for a patient with positive serum CrAg result with
CrAg but asymptomatic for the fluconazole
meningitis preventive ther-
apy section on
the HIV care/
ART follow-up

1
form
6.8 Appropriate medications are provided Triangulate the
for OI s, or HIV related cancers and OI/HIV related
other co morbidities cancers section
with other
medication
or nutritional
supplements
dispensed sec-
tion on the HIV
follow-up form
6.9 Appropriate nutritional supplements are Triangulate the
provided for patient with malnutrition Anthropometry
section with
other medica-
tion or nutri-
tional supple-
ments dispensed
section on the
HIV follow-up
form
6.10 ICT and treatment is provided
Identification of the index case is
docu- mented
Marital status of the index case is
iden- tified
Whether the index case has disclosed
their status to the partner is determined
Partner’s HIV status is identified ICT form
Index’s current status is assessed
Eligibility for partner and family
based ICT is determined based on the
assess- ment
Partner and family based ICT is offered
Acceptance of the offer is determined
Serial number is recorded if offer
is accepted
Elicited contacts are identified and
their details are recorded (Names, ages,
sex, relation)
Test method is agreed (Client,
contrac- tual,, dual, provider) ICT form
Results are collected
PrEP is provided for the partner if the
index case has high VL and partner is
HIV negative (date of PrEP initiation
is documented)
6.11 Follow-up schedule is given to HIV care/ART
the patient follow-up form
7 APPROPRIATE REFERRAL IS 100%
MADE TO A SPECIALIST FOR A
KNOWN HIV PATIENT WITH
INDICATIONS DURING
FOLLOWUP
7.1 Patient with viral load > 1000 Triangulate the
copies/mL for 2nd time is referred to VL result on
MDT (multi disciplinary team) the HIV
care/ART
follow-up form
with the referral
paper in the
patient folder
8 A KNOWN HIV PATIENT’S VIRAL 95%
LOAD IS SUPPRESSED BELOW
1000 COPIES/ ML) IN THE PAST 12
MONTHS
Total standards met per chart
Percentage

References:
National Comprehensive HIV Care
guideline 2018

1
Non-Communicable Diseases Audit Tools
Audit Tool: HTN initial
care
Facility name
Department/unit

1
Audit Topic Initial assessment and management of hypertensive patient in outpatient department
Aim To improve the quality of clinical care for patients who are newly diagnosed with hypertension
Objectives To ensure newly diagnosed hypertensive patients get appropriate initial evaluation
To ensure newly diagnosed hypertensive patients are appropriately investigated
To ensure newly diagnosed hypertensive patients are appropriately treated
To ensure newly diagnosed hypertensive patients get proper counseling
Period of Audit
Inclusion criteria Newly diagnosed hypertensive patient and newly transferred patients/referred patients to the facility
Exclusion criteria (where applicable) Patients with a diagnosis of Secondary hypertension
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to
the individual patient
Data Actual Perfor-

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Source per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Remark
and verifi- for- against
cation mance target
1 A NEWLY HYPERTENSIVE PATIENT’S 100%
CHART IS LABELLED ‘HTN’ ON THE COV-
ER OF THE CHART
1.1 Hypertensive patient’s chart is labeled ‘HTN’ on Patient
cover of the chart chart cov-
er page
2 IDENTIFICATION INFORMATION IS RE- 100%
CORDED FOR A NEWLY HYPERTENSIVE
PATIENT
2.1 Name
2.2 Age
Intake
2.3 Sex form/his-
2.4 Date of visit tory sheet
2.5 MRN
3 APPROPRIATE HISTORY IS TAKEN FOR A 100%
NEWLY HYPERTENSIVE PATIENT
3.1 Hypertension chronic care intake form is used
3.2 Pertinent medical history is taken
Onset and duration of hypertension (for only
known hypertensive patient who is newly trans-
ferred /referred patients to the facility )
Current or previous medication use (hyperten-
sive medication for transferred /referred patients
to the facility and/or medication taken for other
conditions )
At least three personal Risk factors are asked
(history of CVDs such as MI, HF, stroke,
TIA; DM, dyslipidemia, CKD, smoking,
unhealthy diet, excess alcohol intake, physical
inactivity, psychosocial stress) Intake
form/his-
At least one Familial risk factors is asked (Fam- tory sheet
ily history of hypertension, premature CVD,
hypercholesterolemia, diabetes)
Symptoms/signs of hypertension or its compli-
cation are inquired:( Chest pain, shortness of
breath, palpitations, claudication, peripheral
edema, headaches, blurred vision, nocturia,
hematuria, dizziness)
Some symptoms to rule out secondary hyper-
tension are asked : (Muscle weakness/tetany,
cramps, arrhythmias, flash pulmonary edema
,sweating, palpitations, frequent headaches,
snoring, daytime sleepiness, symptoms
sugges- tive of thyroid disease)
4 APPROPRIATE PHYSICAL EXAMINATION 100%
IS PERFORMED FOR A NEWLY HYPERTEN-
SIVE PATIENT
4.1 Blood pressure measurement is taken
4.2 Anthropometric measurements (BMI, waist
circumference) are taken Intake
4.3 Cardiovascular examination is done ( JVP, PMI) form/his-
tory sheet
4.4 Chest is assessed for basal crackles

1
4.5 lower extremity is checked for peripheral edema
5 RELEVANT BASELINE LABORATORY IN- 85%
VESTIGATIONS ARE DONE FOR A NEWLY
HYPERTENSIVE PATIENT
5.1 Blood tests are done
Trian-
CBC
gulate
Urea the plan
Serum creatinine on the
history
Lipid profile
sheet with

1
Fasting blood glucose Investi-
5.2 Sodium and potassium level are determined(for gation
newly transferred/referred patients already on sheet/
HCT and ACE Inhibitors/ARBs) investi-
gation
5.3 Urine test: Dipstick urine test done
papers

5.4 12-lead ECG is done ECG pa-

per and/
or reading
note
6 APPROPRIATE DIAGNOSIS OF HYPERTEN- 100%
SION AND ITS COMPLICATION IS MADE
FOR A NEWLY HYPERTENSIVE PATIENT
6.1 Diagnosis of hypertension is reached after Triangu-
repeated blood pressure measurement of late the
appropriate interval (an additional patient visit, BP mea-
usually surements
with in 1 to 4 weeks after the first measurement) with the
history,
Diagnosis is made without further confirmatory
P/E, lab
readings for hypertensive emergency/urgency
findings
Diagnosis is made without further confirmato- and diag-
ry reading for patient with raised BP and end nosis on
organ damage the Intake
Diagnosis is made with further confirmatory form/
reading for patient with raised BP without end history
organ damage sheet/
6.2 Grading of Hypertension is done Triangu-
6.3 Type of hypertension is late the
specified(primary, secondary) history,
P/E,
6.4 CVD risk stratification is done (WHO laborato- and lab
ry based CVD risk scoring) findings
6.5 Hypertensive related complications are correctly with the
identified MI, IHD, PAD, CKD, CHF) diagnosis
on the
Intake
form/
history
sheet/
7 APPROPRIATE TREATMENT FOR HYPER- 100%
TENSION AND ITS COMPLICATION IS
PROVIDED FOR A NEWLY HYPERTENSIVE
PATIENT
7.1 Patient specific Blood pressure target is set Intake
form/his-
tory sheet
7.2 Appropriate treatment for hypertension is
initiated
Grade one hypertension patient without end
organ damage receive life style interventions Triangu-
for three months. late the
history,
Grade two hypertensive patient received P/E, lab
anti-hypertensive drug (according to national findings
protocol for NCD 2021) in addition to life and
style modification on the date of confirmation diagnosis
of diagnosis with the
Immediate initiation of antihypertensive drug treatment
treatment is made for patient with hypertensive docu-
emergency or end organ damage or high CVD mented
risk on the
Intake
7.3 Statin therapy is initiated for patient with High form/
CVD risk according to national protocol for history
NCD 2021 sheet/
7.4 Identified hypertensive related complications (

1
MI,CKD, CHF, IHD, PAD) are managed
appro- priately or referred to appropriate
specialty care
7.5 Appointment is given
Next appointment date documented in the chart Intake
form/his-
tory sheet
Next appointment date documented in the Patient
registration appoint-
ment
register

1
8 PROPER COUNSELING IS PROVIDED ON 100%
HYPERTENSION CONTROL FOR A NEWLY
HYPERTENSIVE PATIENT
8.1 Counseling on lifestyle modification is
provided (cigarette smoking cessation, Alcohol
intake moderation, regular exercise, weight
reduction, salt restriction, DASH diet)
8.2 Counseling on anti-hypertensive medication Intake
adherence is provided form/his-
tory sheet
8.3 Counseling on possible anti-hypertensive drug
side effect is provided
8.4 Counseling on possible hypertension complica-
tions is provided
9 IDENTIFICATION OF THE PROVIDER IS 100%
DOCUMENTED FOR A NEWLY HYPERTEN-
SIVE PATIENT
9.1 Name and signature of the physician is Intake
clearly documented on the evaluation notes form/his-
tory sheet
Total standards met per chart
Percentage

References:
National NCD management protocol 2021
Audit Tool: HTN follow-up care
Facility name
Department/unit
Audit Topic Hypertension routine care( patients who are on follow-up for one year and more)
Aim To improve the quality of clinical care for hypertensive patients who are on chronic follow-up care
Objectives To ensure hypertensive patients on follow-up care are appropriately evaluated
To ensure hypertensive patients on follow-up care are appropriately investigated
To ensure hypertensive patients on follow-up care are appropriately treated
To ensure proper counseling is provided for hypertensive patients on follow-up care
Period of Audit
Inclusion criteria Patients who have been on follow-up for more than one year
Exclusion criteria (where applicable) Patients who have been on follow-up for less than one year; Patients with a diagnosis of secondary hypertenstion;hyperten-
son in children
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
indi- vidual patient
Actual Perfor-
Data Source
Target

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria and verifica- Remark
for- against
tion
mance target
1 A KNOWN HYPERTENSIVE 100%
PATIENT’S CHART IS LABELLED
‘HTN’ ON THE COVER OF THE
CHART
1.1 Hypertensive patient chart is
Patient chart
labeled ‘HTN’ on cover page
2 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A KNOWN
HYPERTENSIVE PATIENT
DURING FOLLOW-UP
2.1 Name
2.2 Age
Follow-up
2.3 Sex form/history
2.4 Date of visit sheet

1
2.5 MRN
3 APPROPRIATE FOLLOW-UP HIS- 100%
TORY IS TAKEN FOR A KNOWN
HYPERTENSIVE PATIENT
DURING FOLLOW-UP
3.1 Current anti-hypertensive drugs the
patient is taking are identified

1
3.2 Current life style modification
the patient is practicing are
identifed
3.3 Symptoms related to complica-
tions(Chest pain, shortness of breath, Follow-up
palpitations, claudication, peripheral form/history
edema, headaches, blurred vision, sheet
nocturia, hematuria, dizziness are
inquired
3.4 Presence medication side effect
the patient is experiencing is
asessed
3.5 Patient’s practice of self-
monitoring of BP( at home or near
by clinic or pharmacy) is assessed
4 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR A
KNOWN HYPERTENSIVE PA-
TIENT DURING FOLLOW-UP
4.1 Blood pressure measurement is taken
4.2 Anthropometric measurement are
done (BMI, waist circumference)
4.3 Cardiovascular examination is done
(JVP, PMI) Follow-up
4.4 Chest is examined for basal crackles form/history
4.5 Lower extremity is checked for sheet
pe- ripheral edema
4.6 Retinal screening for retinopathy
is done at least once in the past
12 months
5 RELEVANT FOLLOW-UP LABO- 85%
RATORY INVESTIGATION ARE
DONE FOR A KNOWN HY-
PERTENSIVE PATIENT DURING
FOLLOW-UP
5.1 Blood tests are updated yearly:
CBC
Triangulate
Urea, serum creatinine the plan on
lipid profile the history
Fasting blood glucose sheet with
Investigation
5.2 Serum electrolytes(Sodium, potas- sheet/investi-
sium,) are updated at least once in gation papers
the past six month for patients on
HCT,ACE inhibitors and ARBs
5.3 Lipid profile is updated three month Triangulate
after initiation of statin(for patient the plan on
taking statin) the history
5.4 Urine test: urine Dipstick updated at sheet with
least once in the past 12 months Investigation
sheet/investi-
gation papers
5.5 12-lead ECG performed at least ECG paper
once in the past 12 months and reading
note
6 APPROPRIATE HYPERTENSTION 100%
STATUS ASSESMENT IS MADE
FOR A KNOWN HYPERTENSIVE
PATIENT DURING FOLLOW-UP
6.1 Type of hypertension is outlined
6.2 Hypertension control status is deter-
mined Triangulate
the BP mea-
Controlled (BP measurement on 2 surements
consecutive visits is below 140/90) with the
Uncontrolled (BP measurement is history, P/E,
above 140/90 on last visit) lab findings
6.3 Hypertension related complication and diagnosis
are correctly identified (IHD, on the Intake
ACS, stroke, CKD, retinopathy, form/history
PAD) sheet/
6.4 Co morbidities are correctly identi-
fied(dyslipidemia, DM)
7 APPROPRIATE FOLLOW-UP 100%

1
TREATMENT IS PROVIDED FOR
A KNOWN HYPERTENSIVE PA-
TIENT DURING FOLLOW-UP
7.1 For patient with unmet target on life
style modification amlodipine 5mg
is initiated
7.2 Amlodipine dosage is titrated to
10mg for a patient with unmet target
after one month treatment with 5mg
of amlodipine

1
7.3 Dual drug therapy with amlodipine
and hydrochlorothiazide is initiated
for a patient with unmet target after
a one month treatment with 10mg of
amlodipine
7.4 ACE inhibitor is added for a patient
on dual anti-hypertensive drugs(am-
lodipine and hydrochlorothiazide)
treatment for whom target is not met
7.5 ACE inhibitor is titrated to max- Triangulate
imum allowed dose for a patient the history,
with unmet target after a one month P/E, lab find-
treatment with triple therapy ings and di-
agnosis with
7.6 Anti- hypertensive drug adherence
the treatment
assessment and counseling is done
documented
for a patient whose BP target is
on the Intake
unmet after therapy with triple drugs
form/history
at maximal allowed dose
sheet/
7.7 Patient on maximal allowed dose of
triple treatment with good adherence
but unmet BP treatment target is
referred to higher health facility (for
primary hospital)
7.8 Patient on maximal allowed dose of
triple treatment with good adherence
but unmet BP treatment target is
investigated for secondary hyperten-
sion and fourth drug of different
class is initiated
7.9 Patient developing ankle edema
while on amlodipine is put on ACE
inhibi- tor or other class of anti-
hypertensive drug while the dose of
amlodipine is reduced
7.10 Patient developing cough while on
ACE inhibitors are switched to Triangulate
ARBs or other class of anti- the history,
hypertensive drugs P/E, lab find-
ings and di-
7.11 Patient with high CVD risk score
agnosis with
is started on statin
the treatment
7.12 Patient with identified complica- documented
tions ( MI,CKD, CHF, IHD, PAD) on the Intake
is form/history
managed appropriately(interfacility sheet/
or intrafacility consultation/referral
made)
7.13 Appointment is given
Next appointment date documented Intake form/
in the chart history sheet
Next appointment date documented Patient
in the registration appointment
register
8 PROPER COUNSELING IS PRO- 100%
VIDED REGARDING HYPERTEN-
SION CONTROL FOR A KNOWN
HYPERTENSIVE PATIENT
DURING FOLLOW-UP
8.1 Counseling on lifestyle modification
(cigarette smoking cessation,
Alcohol intake moderation, regular
exercise, weight reduction, salt
restriction, DASH diet) is provided
Patient follow
8.2 Counseling on anti-hypertensive up form/his-
medication adherence is given tory sheet
8.3 Counseling on possible anti-hyper-
tensive drug side effect is given
8.4 Counseling on possible hypertension
complications is given
9 APPROPRIATE MONITORING 100%
IS MADE FOR A KNOWN HY-
PERTENSIVE PATIENT DURING
FOLLOW-UP

1
9.1 Patient’s adherence to anti-
hyperten- sive drugs is assessed
9.2 Patient’s adherence to life style Patient follow
modi- fications is assessed up form/his-
9.3 CVD risk assessment and tory sheet
stratifica- tion is done at least once

1
in the past 12 months
10 IDENTIFICATION OF THE PRO- 100%
VIDER IS DOCUMENTED FOR A
KNOWN HYPERTENSIVE PA-
TIENT DURING FOLLOW-UP
10.1 Name and signature of the physician Patient follow
is clearly documented on the up form/his-
evalua- tion notes tory sheet
11 TARGET BLOOD PRESSSURE 70%
IS MET AFTER NINE MONTH
OF FOLLOW-UP
Total standards met per chart
Percentage

References:
National NCD management protocol
2021
Audit Tool: DM initial care
Facility name
Department/unit
Audit Topic Initial assessment and management of diabetic patient in outpatient department
Aim To improve the quality of clinical care for newly diagnosed diabetic patients
Objectives To ensure newly diagnosed diabetic patients get appropriate initial evaluation
To ensure newly diagnosed diabetic patients are appropriately investigated
To ensure newly diagnosed diabetic patients are appropriately treated
To ensure newly diagnosed diabetic patients get proper counseling
Period of Audit
Inclusion criteria Newly diagnosed adult DM patients and newly transferred in/ newly referred patients to the facility
Exclusion criteria (where applicable) Patients already on follow-up in the facility, DM patients with acute complications, gestational diabetes , pediatric
age group
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to
the individual patient
Actual Perfor-
Data
Target

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Source and Remark
for- against
verification
mance target
1 NEWLY DIABETIC PATIENT’S CHART 100%
IS LABELLED ‘DM’ ON THE COVER OF
THE CHART
1.1 Diabetic patient chart is labeled ‘DM’ on Patient
cover of the chart chart
2 IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A NEWLY DIABETIC
PATIENT
2.1 Name
2.2 Age
Intake
2.3 Sex form/his-
2.4 Date of visit tory sheet
2.5 MRN

1
3 APPROPRIATE HISTORY IS TAKEN FOR 100%
A NEWLY DIABETIC PATIENT
3.1 Documented as newly diagnosed diabetic
patient (for newly diagnosed DM)
3.2 Anti-diabetic medication the patient is
getting and type of life style interventions
the patient is implementing are identified
(for transferred in or referred patient)

1
3.3 Current last normal menstrual period and
history of GDM are inquired for a female
patient
3.4 Symptoms suggestive of hyperglycemia:
polyuria, polydipsia, nocturia,
polyphagia, weight loss, fatigue are
inquired
3.5 Any other known illness and other medica-
tion taken by the patient are identified Intake
form/his-
3.6 Risk factors for DM are assessed :age, tory sheet
over- weight/obesity, low birth weight,
physical inactivity, dietary pattern,
smoking, alcohol consumption, substance
use, sleep pattern, diabetes in first degree
relatives, cardiovas- cular diseases and its
risk factors and prior gestational diabetes
(GDM).
3.7 Symptoms suggestive of complications are
assessed: chest pain, Shortness of breath,
leg pain(especially during walking),
blurred vision, numbness, tingling,
weakness of
extremities, slurred speech, symptoms of
hy- poglycemia, Recurrent itching of the
vulva, Frequent skin infections, Slow
healing of skin lesions after minor trauma.
(For type 2 DM suspect or type 1 more than
5 years)
4 APPROPRIATE PHYSICAL EXAMINA- 100%
TION IS PERFORMED FOR A NEWLY
DIABETIC PATIENT
4.1 Patient appearance and body built is de-
scribed: well looking, acutely sick looking,
chronically sick looking, obese,
overweight, well built, slim, emaciated
4.2 Vital signs are measured Intake
form/his-
BP tory sheet
PR
RR
Temperature
4.3 Anthropometric measurements(BMI and
Waist circumference) are taken
4.4 Thyroid palpation is done
4.5 Chest is examined for basal crackles
(espe- cially for type 2 DM suspect)
4.6 CVS is examined: Jugular venous pressure
measured, Point of maximal impulse located
(especially for type 2 DM suspect)
4.7 Skin examination is done
4.8 Foot examination is done: Inspection done
Intake
for foot ulcer, callus, erythema, deformity
form/his-
or infections, Palpation of dorsalis pedis
tory sheet
and posterior tibial pulses, Presence/
absence of patellar and Achilles reflexes,
Determination of proprioception, vibration
and mono- filament sensation, charcoat
arthropathy (especially for type 2 DM
suspect)
4.9 Retinal screening is done (especially for
type 2 DM suspect)
4.10 Comprehensive dental and periodontal ex-
amination is performed (especially for
type 2 DM suspect)
5 RELEVANT INTIAL LABORATORY 85%
INVESTIGATIONS ARE DONE FOR A
NEWLY DIABETIC PATIENT
5.1 FBS or Glycated hemoglobin (HbA1C) or
Postprandial blood sugar (Random Plasma
Glucose) measured
5.2 Urine analysis for dipstick done ( ketone if
Triangu-
blood sugar is above 250 for both Type 1
late the
and Type 2 DM, and protein for type 2 DM
plan on
suspect or type 1DM 5years after
the history
diagnosis)
sheet with
5.3 Creatinine measurement done and GFR Investiga-
estimated (type 2 DM suspect or type tion sheet/
1DM 5years) investiga-
5.4 Fasting lipid profiles (type 2 DM suspect tion papers

1
or type 1DM 5years)
5.5 TSH measurement done in Type 1 DM
patient and dyslipidemia or age>50 years
in Type 2 DM patient
5.6 ECG done for Type 2 DM ECG paper
and read-
ing note
6 APPROPRIATE DIAGNOSIS AND DIS- 100%
EASE CLASSIFICATION (INCLUDING
CO-MORBIDITIES) IS MADE FOR A
NEWLY DIABETIC PATIENT

1
6.1 Patient is correctly classified as Type 1,2 , Triangu-
other endocrinopathy associated diabetes or late the
medication associated diabetes history,
6.2 Complications (retinopathy, nephropathy, P/E,
neuropathy, MI, PAD, ischemic limb and lab
gast- ropaty ….) are correctly identified findings
with the
6.3 Co morbidities are correctly identified diagnosis
on the In-
take form/
history
sheet/
7 APPROPRIATE TREATMENT AND CARE 100%
IS PROVIDED FOR A NEWLY DIABETIC
PATIENT
7.1 Glycemic target is set
7.2 Lifestyle modifications are chosen in
consul- tation with the patient and based on
Triangu-
patient needs ( weight reduction for obese
late the
and over- weight; exercise for those with a
history,
sedentary lifestyle; dietary advice: low sugar,
P/E, lab
high fiber, low fat, fish, vegetables, and fruit;
findings
smoking cessation for smokers; alcohol
and
consumption moderation; proper sleep;
diagnosis
avoiding sub- stance use)
with the
7.3 Appropriate Drug management is provided treatment
for type 2 DM patient document-
ed on the
FBS >126mg/dl and <200mg/dl, life style
Intake
modification and revaluation after 3 month
form/his-
FBS >200mg/dl and <250mg/dl, life style tory sheet/
modification and metformin 500mg po daily
started and escalated to 500mg BID after a
week and revaluation after a month
FBS > 250mg/dl and asymptomatic, life
style modification and metformin 500mg po
BID and glibenclamide 2.5mg daily or
glimepir- ide 1mg daily started and reviewed
after a month to see target achievement and
dose escalation needed
FBS > 250mg/dl and symptomatic or FBS
>300mg/dl, urine ketone is determined and
it is <2+ life style modification and met-
Triangu-
formin 500mg po BID and glibenclamide
late the
2.5mg daily or glimepiride 1mg daily
history,
started and revaluation after a week and
P/E, lab
dose esca- lated if target not achieved
findings
FBS > 250mg/dl and symptomatic or FBS and
>300mg/dl, urine ketone is determined and diagnosis
if greater than or equal to 2+ managed as with the
DKA treatment
7.4 Appropriate drug management is provided document-
for type 1 DM ed on the
Intake
NPH or NPH+ regular insulin 0.4 unit/kg is form/his-
started tory sheet/
If the patient is taking more than 20IU of
NPH insulin: 1/3 is given in evening and
2/3 in the morning
For regular insulin 1/2 dose is given in
the morning and 1/2 is given in the
evening
NPH or NPH+ regular insulin is titrated by
2-4 units every 3-5 days until glycemic
target is achieved
7..5 Patients is given appointment
Next appointment date documented in the Intake
chart form/his-
tory sheet
Next appointment date documented on Appoint-
appointment log book ment log
book/reg-
istration

1
8 PROPER DIABETES SELF-MANAGE- 100%
MENT EDUCATION (COUNSELLING)
IS PROVIDED FOR A NEWLY DIABETIC
PATIENT
8.1 Patient is educated on what diabetes is
8.2 Patient is educated on hypoglycemia sign
and symptom and what to do when it hap-
pens
8.3 Patient is educated in some aspects of life
style modification (weight reduction, Intake

1
smok- ing cessation, alcohol moderation, form/his-
regular exercise, dietary modifications and tory sheet
other substances use)
8.4 Patient is advised on adherence to medica-
tion and lifestyle modification
8.5 Patient is advised on insulin storage and
injection technique
9 IDENTIFICATION OF THE PROVIDER 100%
IS DOCUMENTED FOR A NEWLY A
NEW- LY DIABETIC PATIENT
9.1 Name and signature of the physician is Intake
clear- ly documented on the evaluation form/his-
notes tory sheet
Total standards met per chart
Percentage

References:
National NCD management protocol 2021
Audit Tool: DM follow-up care
Facility name
Department/unit
Audit Topic Diabetic routine care( patients who are on follow-up for one year and more)
Aim To improve the quality clinical care for diabetic patients who are on chronic follow-up care
Objectives To ensure diabetic patients on follow-up care are appropriately evaluated
To ensure diabetic patients on follow-up care are appropriately investigated
To ensure diabetic patients on follow-up care are appropriately treated
To ensure proper counseling is provided for diabetic patients on follow-up care
Period of Audit
Inclusion criteria All adult DM patient on follow up in the facility chronic care clinic/diabetic/referral clinics
Exclusion criteria (where applicable) Diabetic patients who are on follow up for less than one year; patients with acute complications of diabetes; DM associated
with other endcrinopaties, other specific type of DM. Pediatric DM patients.
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient
Perfor-
Data Actual

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Source and perfor- Remark
against
verification mance
target
1 A KNOWN DIABETIC PATIENT’S 100%
CHART IS LABELLED ‘DM’ ON
THE COVER OF THE CHART
1.1 Diabetic patient chart is labeled Patient
DM on cover chart
2 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A KNOWN
DIABETIC PATIENT DURING
FOLLOW-UP
2.1 Name
2.2 Age
Follow up
2.3 Sex form/histo-
2.4 Date of visit ry sheet
2.5 MRN

1
3 APPROPRIATE FOLLOW-UP HIS- 100%
TORY IS TAKEN FOR A KNOWN
DIABETIC PATIENT DURING
FOLLOW-UP
3.1 Symptoms of acute complication are
inquired ( polyuria, polydypsia, noc-
turia, polyphagia, weight loss,

1
fatigue, symptoms of hypoglycemia )
3.2 Symptoms of chronic complication
are inquired (chest pain, Shortness
of breath, leg pain especially during
walking, blurred vision, numbness
and tingling in limbs, weakness of
extremities, Frequent skin Follow up
infections, Slow healing of skin form/histo-
lesions after minor trauma ) ry sheet

3.3 Type of life style modification

under- taken is asked
3.4 Type and dosage of anti-diabetic
and other medication being taken
are identified
3.5 Patient’s conception need is
assessed at every visit
4 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS PERFORMED FOR
A KNOWN DIABETIC PATIENT
DURING FOLLOW-UP
4.1 Vital signs are measured
BP
PR
RR
Temperature
4.2 Anthropometric measurements are Follow-up
taken chart/histo-
BMI ry sheet
Waist circumference measured
4.4 Skin examination is done(
Acanthosis nigricans, infections,
insulin injection sites)
4.5 Foot examination is performed
Detailed examination performed
annually(Palpation of dorsalis pedis
and posterior tibial pulses, Presence/
absence of patellar and Achilles
reflexes, Determination of proprio-
ception, vibration and monofilament
sensation)
Inspection done for foot ulcer, callus,
erythema, deformity, foot arch loss
or infections at every visit)
4.6 Retinal screening is done Follow-up
chart/histo-
Retinal screening done at least once
ry sheet
in the last two years for Type 1
diabe- tes.
Retinal screening done at least
once in the last one year for Type
2 diabetes.
4.7 Comprehensive dental and periodon-
tal examination is performed at least
once in the last one year for type 2
DM and type 1DM patient who has
been diabetic for more than 5 years
5 RELEVANT FOLLOW-UP LABO- 85%
RATORY INVESTIGATION ARE
DONE FOR A KNOWN
DIABETIC PATIENT DURING
FOLLOW-UP
5.1 FBS is measured on every visit
5.2 Urine dipstick test is done at
appro- priate interval
Annually for patient without symp-
toms of kidney disease
Triangulate
If urine protein is detected,
the plan on
dipstick repeated after 3 months
the history
5.3 HBA1c is measured biannually sheet with
5.4 Creatinine measurement is done Investiga-
and GFR estimated at appropriate tion sheet/
investiga-

1
interval
tion papers
Creatinine measurement done and
GFR estimated annually for Type
2 DM
Twice per year if GFR is between
30-60
5.5 Lipid profile is measured at an Triangulate
appro- priate interval the plan on
Fasting lipid profiles updated the history
annual- ly for pt who is not taking sheet with
statin Investiga-
tion sheet/
If on statin, Fasting lipid profile investiga-

1
repeated after six months of initiation tion papers
of statin
5.6 ECG is done annually for Type 2 DM ECG pa-
per/ ECG
reading
6 APPROPRIATE DIAGNOSIS AND 100%
DISEASE CLASSIFICATION (IN-
CLUDING CO-MORBIDITIES) IS
MADE FOR A KNOWN DIABETIC
PATIENT DURING FOLLOW-UP
6.1 Patient is correctly classified as Triangulate
Type 1 DM ,Type 2 DM the history,
6.2 Correct Glycemic control status(con- P/E, and
trolled or uncontrolled in compar- lab findings
ison with previously set target) is with the
determined diagnosis
on the
6.3 Existing complications are Follow-up
correctly identified chart/histo-
ry sheet
7 APPROPRIATE TREATMENT 100%
AND CARE IS PROVIDED FOR
A KNOWN DIABETIC PATIENT
DURING FOLLOW-UP
7.1 Appropriate Drug management is Triangulate
provided for type 2 DM patient the history,
For patient in whom glycemic target P/E, lab
is achieved with life style modifica- find-
tion, adherence to life style ings and
modifica- tion is continued diagnosis
with the
For patient in whom glycemic treatment
target is not achieved with life style document-
mod- ification alone, metformin ed on the
500mg po daily is initiated, and the Follow-up
dose of metformin is escalated to chart/histo-
500mg bid after one week ry sheet
For a patient in whom glycemic
target is not achieved with life style
modification and maximum dose of
metformin, glibenclaminde or glime-
pride is added
For patient in whom glycemic target
is not achieved with life style met-
formin 500mg po bid , and maximum
dose of glibenclaminde or
glimepride, insulin is initiated
Patient whose FBS > 250mg/dl and
symptomatic or FBS >300mg/dl, Triangulate
urine ketone is determined and if the history
greater than or equal to 2+ managed and P/E,
as DKA lab find-
7.2 Appropriate drug management is ings, and
provided for type 1 DM diagnosis
with the
NPH or NPH+ regular insulin 0.4 treatment
unit/kg is continued document-
If the patient is taking more than ed on the
20IU of NPH insulin: 1/3 is given Follow-up
in evening and 2/3 in the morning chart/histo-
ry sheet
For regular insulin 1/2 dose is given
in the morning and 1/2 is given in the
evening
NPH or NPH+ regular insulin is
titrated by 2-4 units every 3-5
days until glycemic target is
achieved
7.3 Co-morbid illness are identified
during follow-up visit and managed
appropriately
7.4 Identified DM associated
complica- tions are managed
appropriately
7.5 Patients is given appointment
Next appointment date documented Follow-up
in the chart chart/histo-

1
ry sheet
Next appointment date documented Appoint-
in the registration ment log
book
8 PROPER COUNSELING IS PRO- 100%
VIDED FOR A KNOWN DIABETIC
PATIENT DURING FOLLOW-UP
8.1 Counseling on adherence is given
Adherence counseling to chosen
lifestyle modification is given

1
(smok- ing cessation, alcohol
moderation, dietary, weight
reduction, exercise) Follow-up
chart/histo-
Adherence counseling for pharmaco- ry sheet
logic treatment given
8.2 Reminder is given on
hypoglycemic symptoms
8.3 Counseling on other DM related
complication is given
9 APPROPRIATE REFERRALTO 100%
A SPECIALIST IS MADE FOR
A KNOWN DIABETIC
PATIENT DURING FOLLOW-
UP WITH INDICATIONS
9.1 Patient with identified micro Triangulate
vascular and macro vascular the history,
complication referred to higher level P/E and di-
9.2 Patient with recurrent hypoglycemia agnosis on
despite dose adjustment is referred follow-up
to higher level chart/his-
tory sheet/
9.3 Patient with failure to achieve referral
glycemic target despite optimal sheet/refer-
dose adjustment referred to higher ral register
level
10 APPROPRIATE MONITORING IS 100%
MADE FOR A KNOWN DIABETIC
PATIENT DURING FOLLOW-UP
10.1 Adherence to life style modification
is assessed on every visit
Patients adherence to physical
activity advice is assessed Follow-up
Patients adherence to dietary modifi- chart/histo-
cations is assessed ry sheet
Patients adherence to alcohol mod-
eration and smoking cessation
advice is assessed
10.2 Adherence to medication is
assessed on every visit Follow-up
chart/histo-
10.3 Patient’s ways of insulin storage ry sheet
and injection technique checked
11 IDENTIFICATION OF THE 100%
PRO- VIDER IS DOCUMENTED
FOR A KNOWN DIABETIC
PATIENT DURING FOLLOW-
UP
11.1 Name and signature of the physician Follow up
is clearly documented on the sheet/histo-
evalua- tion notes ry sheet
11.2 Name and signature of the
Referral
physician is clearly documented on
paper
referral paper
12 PATIENT’S BLOOD GLUCOSE 70%
Follow-up
LEVEL IS UNDER CONTROL FOR
chart/his-
THE LAST TWO PREVIOUS VISITS
tory sheet/
(FBG LEVEL BETWEEN 80-130MG/
investiga-
DL ON THE LAST TWO VISIT
tion paper
AND HGA1C LEVEL OF <7%
Total standards met per chart
Percentage

References:
National NCD management protocol
2021

1
Audit Tool: DKA
Facility name
Department/unit
Audit Topic Management of adult patients with DKA
Aim To improve the quality of clinical care for

1
adult patients diagnosed with DKA
Objectives To ensure adult diabetic patients who developed DKA are appropriately evaluated
To ensure adult diabetic patients who developed DKA are appropriately investigated

To ensure adult diabetic patients who developed DKA are appropriately treated

To ensure proper counseling is provided to adult diabetic patients who developed DKA
Inclusion criteria All adults managed as DKA in emergency and inpatient departments (medical ward, ICU)
Exclusion criteria (where applicable) Diabetic patients with DKA in pediatric age group;
Individual with marked hyperglycemia but ketone body less than 2+
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Data Source Actual
Target

mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria and verifi- perfor- Remark
against
cation mance
target
1 IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A DIABETIC PATIENT
WHO DEVELOPED DKA
1.1 Name
1.2 Age
1.3 Sex Patient
chart cover
1.4 Date of visit
1.5 MRN
2 APPROPPRIATE HISTORY IS TAKEN 100%
FOR A DIABETIC PATIENT WHO DE-
VELOPED DKA
2.1 Identified whether the patient is
newly diagnosed or known DM History
patient sheet
2.2 Insulin dosage and adherence to drug is
asked
2.3 Life style modification and adherence
is asked
2.4 Symptom suggestive of DKA are inquired
(polyuria, polydypsia, polyphagia, general-
ized body weakness, abdominal pain,
vom- iting, change of mentaion, fruity
breath)
2.5 History of precipitating factors for DKA is
taken
Infection: cough, fever, headache,
diarrhea, dysuria History
Acute major illness: chest pain, shortness sheet
of breath, extremity weakness, sudden loss
of consciousness
Drugs: glucocorticoids, higher-dose thi-
azide diuretics, sympathomimetic agents
(e.g., dobutamine), and second-generation
“atypical” antipsychotic agents(clozapine,
risperidone , olanzapine, risperidone)
Omission of insulin
Insulin storage
Substance abuse
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS DONE FOR A DIABETIC
PATIENT WHO DEVELOPED DKA
3.1 Vital signs are measured
BP
PR
RR
Temprature
Spo2 (oxygen saturation)
3.2 Degree of dehydration: skin turgor, and
oral mucosa are assessed
History
3.3 Respiratory pattern and depth are assessed sheet
3.4 Chest is examined for sign of infection or
congestion

1
3.5 CVS is examined (Jugular venous
pressure, heart rhythm, pericordial
examination)
3.6 CNS is examined (Mental status
examina- tion, meningial sign, neurologic
deficit)
3.7 Insulin injection site is examined
4 RELEVANT LABORATORY INVESTI- 75%
GATIONS ARE DONE FOR A DIABETIC
PATIENT WHO DEVELOPED DKA
4.1 Serum blood glucose and urine ketones are
determined immediately
4.2 EKG evaluating for signs of severe hypoka-
lemia is done immediately

1
4.3 Blood chemistry is determined with in an
hour Triangulate
CBC (including
Chemistry-Na+, K+, Cl done the time)
history/
Chemistry- BUN, Creatinine done order
RBS sheet with
4.4 Patient is investigated for investiga-
precipitating causes tion sheet/
paper
Urinalysis,
Cultures of urine, sputum, and blood (for
tertiary hospitals only)
Serum lipase and amylase etc. (for tertiary
hospitals only)
Chest x-ray Triangulate
history/
order sheet
with x ray
readings
5 APPROPRIATE AND TIMELY DIAGNO- 100%
SIS OF DKA IS MADE FOR A DIABETIC
PATIENTS WHO DEVELOPED DKA
5.1 Diagnosis is made in the presence hyper-
glycemia: Blood sugar >250mg/dl plus History
and urine ketone > +1 plus and glucosuria sheet/order
sheet
5.2 Precipitating factor is identified
6 APPROPRIATE INITIAL MANAGE- 100%
MAENT OF DKA STARTED DIABETIC
PATIENTS WHO DEVELOPED DKA
6.1 Patient’s airway, breathing, and History
circulation is stabilized sheet/order
Airway checked for any obstruction and sheet/medi-
removed cation sheet
For desaturated patient, O2 is given History
via mask or nasal prongs sheet/order
IV line secured with large bore size sheet/medi-
iv canula and N/S cation sheet
6.2 Timely and appropriate IV fluids
resuscita- tion is made
1 liters of 0.9 % Normal saline is
given immediately over 1 hour
For hemodynamically unstable, Normal
saline 1 Liter is given over 30 minutes.
And repeated until the patient became
stable
For hemodynamically stable, Normal
saline 1to 2 Liter is given over 2hours
Over next 24 to 48 hrs a total of 6 to 9 liters
of fluid given
Fluid is changed to 5% DNS or 5%
DW when RBS drops below 250mg/dl
6.3 Insulin treatment is started as soon as
needed Triangulate
Urine ketone +1 asymptomatic patient, history
resucitated with iv fluid and urine ketone sheet/prog-
is repeated after 1 hr and became ress note/
negative order
,then insulin dosage is escalated by 10 sheet with
to 20 % of previous dose, discharged medication
with sheet
appointement for reevaluation after 2-3 day
at outpatient department or NCD clinic or
diabetic referral clinic
Symptomatic patient or ketone >1+, 0.1
to 0.2 initial IV bolus regular insulin
given and 0.1iu/kg/hr IV or 0.2iu/kg/hr
SC insulin given until urine ketone clears
and dosage increased by 50% if blood
sugar didn’t drop by more than 50mg/dl
with in an hour
When blood sugar drops less than 200mg/

1
dl regular insulin being given is reduced
by 50%
6.4 Potassium supplementation is provided
Serum potassium >5.5mEq/L KCL
not given but monitoring continued
Serum potassium 3.3-5.5mEq/L 2vials
of kcl in each bag of NS given
Serum potassium < 3.3 mEq/L 3-4 vials
of kcl in each bag of NS given and
insulin withholded until it became >3.3
mEq/L

1
If Laboratory for serum potassium not Triangulate
available 2 ampoule of kcl added in history
each bag of NS as soon as urine output sheet/prog-
is ade- quate(>50 ml/hr) ress note/
6.5 Transition to long acting insulin is made order
sheet with
IV regular insulin Is continued for 1-2
medication
hrs after the start of long acting insulin
sheet
Long acting insulin started as soon as DKA
resolved (0.4 u/kg for insulin naïve
patients, usual regimen is resumed for
patient who was previously on insulin with
dosage titration 2to 3 days)
6.6 Treatment for the identified precipitating
factor is provided
6.7 Patient is given appointment
Next appointment date documented in the History
chart sheet/ prog-
ress note/
Follow up
sheet
Next appointment date documented in the Patient ap-
registration pointment
log book
7 APPROPRIATE MONITORING IS MADE 100%
FOR DIABETIC PATIENT WHO DEVEL-
OPED DKA
7.1 Vital signs are taken 1 hrly until patient Follow up
became stable sheet/vital
sign chart
7.2 Hydration status is examined 1 hrly until Triangu-
patient become hemodynamically stable late follow
7.3 Mental status examination is done 6hrly up sheet/
Progress
7.4 Fluid input and output is monitored 6hrly note with
medication
sheet
7.5 Blood sugar is monitored 1hrly
Triangulate
7.6 Urinary ketone is monitored 2hrly follow up
7.7 Electrolytes are monitored 6hrly Na+, sheet with
K+ (except for primary hospitals) investiga-
7.8 BUN and creatinine are measured daily tion paper
8 PROPER COUNSELING IS PROVIDED 100%
FOR A DIABETIC PATIENT WHO DE-
VELOPED DKA
8.1 What diabetes mellitus is
8.2 How diabetes mellitus is managed (
lifestyle modification, drugs)
Follow up
8.3 Insulin injection technique and storage sheet/prog-
8.4 Sign and symptoms of hypoglycemia ress note
and its management
8.5 Complications related to diabetes mellitus
9 IDENTIFICATION OF THE 100%
PROVIDER IS DOCUMENTED FOR A
DIABETIC PATIENT WHO
DEVELOPED DKA
9.1 Name and signature of the physician is History
clearly documented on the history sheet sheet
9.2 Name and signature of the physician Order
is clearly documented on all order sheets
sheets
9.3 Name and signature of the physician is Follow-up
clearly documented on all progress sheets
notes
9.4 Name and signature of the nurse is Medication
clearly documented on all medication sheets
sheets
10 DIABETIC PATIENT WHO DEVELOPED 100% Negative
DKA WENT OUT OF DKA urine ke-
tones (con-
firmed and
repeated in
1-2 hrs) and
BG < 200
mg/dL and

1
Patient is
able to eat
Total standards met per chart
Percentage

References:
National NCD management protocol 2021
Audit Tool: Asthma initial care
Facility name
Department/unit
Audit Topic Newly diagnosed asthmatic patients in outpatient department
Aim To improve the quality of clinical care for newly diagnosed asthmatic patients in outpatient department

2
Objectives To ensure newly diagnosed asthmatic patients are appropriately evaluated
To ensure newly diagnosed asthmatic patients are appropriately investigated
To ensure newly diagnosed asthmatic patients are appropriately treated
To ensure proper counseling is provided for newly diagnosed asthmatic patients
Period of Audit
Inclusion criteria All adult asthmatic patient new for the facility (Newly diagnosed or newly transferred in/referred patients)
Exclusion criteria (where applicable) COPD patients and children with asthma diagnosis, asthma exacerbation, and patient on follow up for more than
3 month.
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to
the individual patient
Actual Perfor-
Data

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Source and Remark
for- against
verification
mance target
1 A NEWLY ASTHMATIC PATIENT’S CHART 100%
IS LABELLED ‘ASTHMA’ ON THE COVER
OF THE CHART
1.1 Asthmatic patient’s chart is labeled ‘asthma on Patient
cover page of the chart chart
2 IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A NEWLY ASTHMATIC
PATIENT
2.1 Name
2.2 Age
2.3 Sex History
sheet
2.4 Date of visit
2.5 MRN
3 APPROPRIATE HISTORY IS TAKEN FOR A 100%
NEWLY ASTHMATIC PATIENT
3.1 Symptoms suggestive of asthma: Cough, diffi-
culty breathing, tight chest and/or wheezing are
inquired
3.2 Asthma attack is characterized well
Day time attack frequency per week/month
Night time attack frequency per weak/month
Frequency of use of beta agonists per week
Response to beta agonists for known asthmatic
patient
3.3 Presence of previous diagnosis of asthma
is asked History
sheet
3.4 Presence of symptoms since childhood or
early adulthood are asked (for new patient)
3.5 For new asthmatic patient risk factors for asthma
are inquired: (Family history of asthma, History
of hay fever, eczema and/or allergies, occupa-
tional exposure, air pollution, tobacco, obesity)
3.6 Asthma triggers (allergens, upper respiratory
tract viral infection, exercise, stress, drugs (B-
blockers, aspirin), cold air, irritants (paint
fumes, house hold spray) are identified
4 APPROPRIATE PHYSICAL EXAMINATION 100%
IS PERFORMED FOR A NEWLY ASTHMATIC
PATIENT
4.1 Vital signs measured
BP
PR
RR
Temperature
History
SpO2 (oxygen saturation)
sheet
4.2 Presence or absence of signs of respiratory
distress(flaring of ala nasi, use of accessory
rep- aratory muscle, unable to complete a
sentence, depth and rate of breathing) are
assessed
4.3 Chest is auscultated

2
5 RELEVANT DIAGNOSTIC WORKUP IS 70%
DONE FOR A NEWLY ASTHMATIC PATIENT
5.1 Lung function is determined before and after
inhalational bronchodilators
Peak Expiratory Flow Rate
(PEFR)measured using peak flow meter Triangulate
(primary hospital) the plan on
Spirometry done and FEV to FVC ratio the history

2
deter- mined (general hospital and above) sheet with
5.2 Additional tests are done for patient with com- Investiga-
plications or co morbidities tion sheet/
investiga-
CBC tion papers

Sputum examination done if patient has produc-

tive cough(Gram stain, AFB stain, GeneXpert),
CXR
6 APPROPRIATE DIAGNOSIS AND DISEASE 100%
CLASSIFICATION IS MADE FOR A NEWLY
ASTHMATIC PATIENT
6.1 Asthma management step is determined Triangulate
the history,
P/E, and
6.2 Lung function determined(FEV1/FVC ratio)or lab find-
PEFR ings with
the diag-
6.3 Complications and co-morbidities correctly nosis on
identified the history
sheet
7 APPROPRIATE TREATMENT AND CARE 100%
IS PROVIDED FOR A NEWLY ASTHMATIC
PATIENT
7.1 Asthma action plan is developed and given Action
to the patient plan tem-
plate
7.2 The level of step needed to control the symptoms
is correctly determined and appropriate drug
therapy is initiated accordingly
Patient with symptoms less than twice per
month is identified as Step 1: and Low dose
inhaled Beclomethasone 100µg taken whenever
Inhaled Salbutamol (SABA) is taken with SABA
PRN base is initiated
Patient with symptoms twice a month or more,
but less than daily, is identified as Step 2 and
Standing dose of daily Beclomethasone inhaler Triangulate
200µg (1 puff) BID plus Salbutamol puff PRN is the symp-
initiated toms on
the history
Patient with symptoms most days, or waking
and lung
with asthma once a week or more, is identified
function
as Step 3 and Standing medium dose of beclo-
result on
metasone 400ug(2puffs of 200ug) BID alone or
investiga-
medium dose of beclometasone 200ug(1puffs of
tion with
200ug) BID plus theoephedrine 1 tab po BID/
level of
TID or low dose maintenance budesonide/for-
step on the
moterol is started
diagnosis
Patient with symptoms most days, or waking with treat-
with asthma once a week or more, and low ment doc-
lung function, is identified as Step 4 and High umented
dose Beclomethasone 600μg puffs BID (3 on history
puffs of 200μg BID) + Theophedrine 1 tab PO sheet
bid or tid or medium dose maintenance
budesonide/for- moterol is started
Patient with symptoms most days, or waking
with asthma once a week or more, and low lung
function treated with High dose Beclometha-
sone 600µg puffs BID (3 puffs of 200µg BID) +
Theophedrine 1 tab PO bid or tid or medium
dose maintenance budesonide/formoterol and
not responding, predinsolone 10mg po daily or
high dose ICS-formoterol is added
7.3 Appointment is given to the patient
Appointment is documented on patient chart History

2
sheet/Pa-
tient chart
Appointment is documented on appointment Patient ap-
log book pointment
log book
8 PROPER COUNSELLING IS PROVIDED FOR 100%
A NEWLY ASTHMATIC PATIENT
8.1 Smoking cessation advice is provided
8.2 Advice is provided on regular physical activity
8.3 Patient is advised to avoid occupational asthma
triggers History

2
8.4 Patient is advised to avoid known allergens sheet
8.5 Treatment adherence counseling is provided
8.6 Demonstration on inhaler techniques is made
and documented
9 APPROPRIATE REFERRAL TO HIGHER 100%
HEALTH FACILITIES DONE IS MADE FOR A
NEWLY ASTHMATIC PATIENT WITH INDI-
CATION (ONLY FOR PRIMARY HOSPITALS
9.1 Patient suspected of occupational asthma is refe Triangulate
rred the diag-
9.2 Patient on whom the diagnosis of asthma nosis on
is uncertain is referred the history
sheet with
referral
paper
10 IDENTIFICATION OF THE PROVIDER IS 100%
DOCUMENTED FOR A KNOWN HYPER-
TENSIVE PATIENT WHO IS ON FOLLOW-UP
10.1 Name and signature of the physician is History
clearly documented on the evaluation notes sheet
10.2 Name and signature of the physician is Referral
clearly documented on referral paper paper
Total standards met per chart
Percentage

References:
National NCD management protocol 2021
Audit Tool: Asthma follow-up care
Facility name
Department/unit
Audit Topic Asthma chronic follow-up care in outpatient department
Aim To improve the quality of clinical care for adult asthmatic patients on chronic asthma follow-up care
Objectives To ensure asthmatic patients on follow-up care are appropriately evaluated
To ensure asthmatic patients on follow-up care are appropriately investigated
To ensure asthmatic patients on follow-up care are appropriately treated
To ensure proper counseling is provided for asthmatic patients on follow-up care
Period of Audit
Inclusion criteria All adult patients who are on follow up for 6 month or more
Exclusion criteria (where applicable) COPD patients and children with asthma diagnosis, asthma exacerbation
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Actual Perfor-
Data Source

chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17
chart 18
chart 19
Tar- per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria and verifica- Remark
get for- against
tion
mance target
1 A KNOWN ASTHMATIC PATIENT’S 100%
CHART IS LABELLED ‘ASTHMA’
ON COVER OF THE CHART
1.1 Asthmatic patient chart is labeled
Patient chart
with asthma on cover page of the
folder
2 IDENTIFICATION INFORMATION RE- 100%
CORDED FOR A KNOWN ASTHMATIC
PATIENT DURING FOLLOW-UP
2.1 Name
2.2 Age
Follow up
2.3 Sex sheet/history
2.4 Date of visit sheet
2.5 MRN
3 APPROPRIATE FOLLOW-UP HISTORY 100%

2
IS TAKEN FOR A KNOWN ASTHMATIC
PATIENT DURING FOLLOW-UP
3.1 Asthma control status is assessed in Follow up
each visit using proper format sheet/history
sheet
Day time attack frequency per
week/ month
Night time attack frequency per
weak/ month
Frequency of use of beta agonists per week
Response to beta agonists
Follow up

2
3.2 Assessment of risk factors for poor sheet/history
outcomes is done (High SABA use (≥3 sheet
canisters/year), ≥1 exacerbation in last
12 months, Incorrect inhaler technique
and/ or poor adherence, Smoking,
depression, anxiety, Lack of Inhaled
Corticosteroid (ICS) treatment,
occupational exposure, Mucus hyper
secretion
4 APPROPRIATE PHYSICAL EXAMINA- 100%
TION IS PERFORMED FOR A
KNOWN ASTHMATIC PATIENT
DURING FOL- LOW-UP
4.1 Vital signs are measured
BP
PR
RR
Temperature Follow up
SpO2 (Oxygen saturation) sheet/history
4.2 Signs of respiratory distress are assessed sheet
(flaring of ala nasi, use of accessory
rep- aratory muscle use, unable to
complete a sentence, depth and rate of
breathing)
4.3 Chest is auscultated
5 RELEVANT DIAGNOSTIC WORKUP IS 70%
DONE FOR A KNOWN ASTHMATIC
PATIENT DURING FOLLOW-UP
5.1 Lung function is determined Triangulate
Peak Expiratory Flow Rate the plan on
(PEFR)mea- sured (primary hospital) the Follow
up sheet/
Spirometry done (general hospital and history sheet
above) with Investi-
gation sheet/
investigation
papers
5.2 Additional lab tests are done for complica- Triangulate
tions or co morbidities the plan on
CBC the Follow
up sheet/
history sheet
Sputum examination (Gram stain, with Investi-
AFB stain, GeneXpert) gation sheet/
CXR investigation
papers
6 APPROPRIATE DIAGNOSIS AND 100%
DISEASE CLASSIFICATION IS MADE
FOR A KNOWN ASTHMATIC PATIENT
DURING FOLLOW-UP
6.1 Asthma management step is determined
Triangulate
6.2 Status of control is determined the history,
6.3 Lung function is determined(FEV1/FVC P/E, and lab
ratio)or PEFR findings with
6.4 Level of asthma control is determined the diagnosis
on the histo-
6.5 Complications and co-morbidities are
ry sheet
correctly identified
7 APPROPRIATE TREATMENT IS PRO- 100%
VIDED FOR A KNOWN ASTHMATIC
PATIENT DURING FOLLOW-UP
7.1 The level of step needed to control the Triangulate
symptoms is redetermined and appropriate the symp-
drug therapy provided accordingly toms on the
Patient with symptoms less than twice history and
per month is identified as Step 1 and lung func-
Low tion result
dose inhaled Beclomethasone 100µg on investi-
taken whenever Inhaled Salbutamol gation with
(SABA) is taken with SABA PRN base is level of step
provided on the diag-
nosis with
Patient with symptoms twice a month or treatment
more, but less than daily, is identified as documented
Step 2 and Standing dose of daily Beclo- on follow up
methasone inhaler 200µg (1 puff) BID sheet/history
plus Salbutamol puff PRN is provided sheet

2
Patient with symptoms most days, or
wak- ing with asthma once a week or
more, is identified as Step 3 and Standing
medium dose of beclometasone
400ug(2puffs of 200ug) BID alone or
medium dose of be- clometasone
200ug(1puffs of 200ug) BID plus Triangulate

2
theoephedrine 1 tab po BID/TID or low the symp-
dose maintenance budesonide/formo- toms on the
terol is provided history and
lung func-
Patient with symptoms most days, or tion result
waking with asthma once a week or more, on investi-
and low lung function, is identified as gation with
Step 4 and High dose Beclomethasone level of step
600μg puffs BID (3 puffs of 200μg BID) + on the diag-
The- ophedrine 1 tab PO bid or tid or nosis with
medium dose maintenance treatment
budesonide/formoterol is provided documented
Patient with symptoms most days, or on follow up
wak- ing with asthma once a week or sheet/history
more, and low lung function treated with sheet
High dose Beclomethasone 600µg puffs
BID (3 puffs of 200µg BID) +
Theophedrine 1 tab PO bid or tid or
medium dose maintenance
budesonide/formoterol and not respond-
ing, predinsolone 10mg po daily or high
dose ICS-formoterol is added
7.2 Treatment titrated according to the step Triangulate
determined the diagnosis
Step-up treatment done if asthma poorly with the
controlled treatment
provided
Step-down treatment if asthma is on the
well controlled for at least 3 months follow-up/
history sheet
7.3 Appointment is given the patient
Next appointment date documented in the Follow up
chart sheet/history
sheet
Next appointment date documented in the Patient
logbook appointment
log book
8 PROPER COUNSELLING IS PROVIDED 100%
FOR A KNOWN ASTHMATIC PATIENT
DURING FOLLOW-UP
8.1 Smoking cessation advice is provided
8.2 Advice is provided on regular
physical activity
8.3 Patient is advised to avoid occupational
asthma triggers Follow up
sheet/history
8.4 Patient is advised to avoid known allergens
sheet
8.5 Treatment adherence counseling is pro-
vided
8.6 Demonstration on inhaler techniques is
made and documented
9 APPROPRIATE MONITORING IS MADE 100%
FOR A KNOWN ASTHMATIC PATIENT
DURING FOLLOW-UP
9.1 Patient’s adherence to treatment is assessed
9.2 Inhaler technique is observed and docu-
mented
9.3 Follow-up care is provided at
appropriate interval
After 6 weeks of initiation or change Follow up
of treatment sheet/history
Every 6 weeks during pregnancy sheet
Within 1 week of exacerbation
Every 3 months during follow up
Every 6 months for those with
adequate control
10 APPROPRIATE REFERRAL TO A 100%
SPECIALIST IS MADE FOR A KNOWN
ASTHMATIC PATIENT WITH
INDICA- TIONS DURING FOLLOW-
UP
10.1 Patient whose asthma remains poorly Triangulate
controlled is referred to higher level the history,
10.2 Patient experiencing significant side effects P/E and
from medications is referred to higher diagnosis on
level the history
sheet/fol-
10.3 Patient who required regular oral pred- low-up sheet

2
nisolone to maintain control is referred to with referral
higher level paper
11 IDENTIFICATION OF THE 100%
PROVIDER IS DOCUMENTED FOR A
KNOWN ASTHMATIC PATIENT
DURING FOL- LOW-UP
11.1 Name and signature of the physician Follow up
is clearly documented on the sheet/history
evaluation notes sheet

2
11.2 Name and signature of the physician Referral
is clearly documented on referral paper
paper
12 A KNOWN ASTHMATIC PATIENT’S 100% Symptoms
ASTHMA ATTACK IS CONTROLLED are pres-
ent only
during the
day, Use of
salbutamol
is limited
to no more
than twice a
week, Night
symptoms
occur fewer
than twice a
month, no
or minimal
limitation
of daily
activities,
No severe
exacerba-
tions within
a month,
PEFR > 80%
of predicted

Total standards met per chart

Percentage

References:
National NCD management protocol 2021
Mental Health Audit Tools
Audit Tool: Schizophrenia initial care
Facility name
Department/unit
Audit Topic Schizophrenia initial care
Aim To improve the quality of clinical care provided to patients with schizophrenia
Objectives To ensure patients with schizophrenia are evaluated appropriately
To ensure risk assessment is done for individuals with schizophrenia
To ensure patients with schizophrenia are managed appropriately
Period of Audit
Inclusion criteria All patients with schizophrenia presenting at psychiatry OPD
Exclusion criteria (where applicable)
If completed give ‘Yes’ if not give ‘no’ Give NA if the criterion does
not apply to the individual patient
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to
the individual patient
Perfor-
Data Source Actual

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A PATIENT WITH
SCHIZOPHRENIA
1.1 Name
1.2 Age
1.3 Sex History
1.4 Date of Evaluation Sheet (on
each sheet of
1.5 MRN evaluation
1.6 Source of referral note)
1.7 Source of information (From patient and
collateral)
2 APPROPRIATE PSYCHIATRIC HISTO- 100%

2
RY AND MENTAL STATE EXAMINA-
TION IS DONE FOR A PATIENT
WITH SCHIZOPHRENIA
2.1 Presence of core symptoms(delusion,
hallucination, disorganized speech)
are assessed
2.2 Presence of disorganized or catatonic
behavior, negative symptoms are
assessed

2
2.3 Presence of symptoms for at least
six months period is ascertained History Sheet
2.4 Presence for manic episode is checked
2.5 Presence of medical condition that
may explain the above symptoms is
assessed
2.6 Presence of substance misuse that may
explain the above symptoms is
assessed
2.7 Level of dysfunctionality is assessed
2.8 Screening for medical conditions like
NCDs-HTN,DM and neurological con- Triangulate
ditions is done History
Sheet and
2.9 Screening for HIV and Tuberculosis is lab report
done
2.10 Mental status examination is done History sheet
3 APPROPRIATE PHYSICAL EXAMINA- 100%
TION IS DONE FOR A PATIENT
WITH SCHIZOPHRENIA
3.1 Vital signs are measured
Blood pressure
Pulse rate
Temperature History sheet
Respiratory rate
3.2 Neurologic examination related to pa-
tient’s history is done
4 RELEVANT INVESTIGATIONS 75%
ARE DONE FOR A PATIENT WITH
SCHIZOPHRENIA
4.1 CBC
4.2 Organ function (LFT, RFT)
Triangulate
4.3 Metabolic (FBS, LDL, HDL, triglycerides) History sheet
4.4 Pertinent imaging with Lab
report
4.5 HCG (in female patients of
reproductive age)
5 APPROPRIATE RISK ASSESSMENT 100%
IS DONE FOR A PATIENT WITH
SCHIZOPHRENIA
5.1 Experience of suicidal thought,
plans, intent or/and attempt is
assessed
5.2 Presence of infanticide or homicide History Sheet
(thought, plans, intent, attempt), neglect,
abuse towards others are assessed
5.3 Experience of neglect, abuse and
mal- treatment are assessed
6 APPROPRIATE DIAGNOSIS IS MADE 100%
FOR A PATIENT WITH
SCHIZOPHRE- NIA
6.1 Diagnosis is made based on the presence
of at least one from 2.1 and another one Triangulate
from 2.2; or presence of at least 2 from history,
2.1, plus presence of 2.3, P/E and
dysfunctionality, absence of other mental investigation
illnesses, medical conditions and findings with
substance use that can explain the diagnosis on
psychosis history sheet
6.2 Co morbid diagnoses are made when
appropriate
7 APPROPRIATE PHARMACOTHERAPY 100%
IS INITIATED FOR A PATIENT WITH
SCHIZOPHRENIA
7.1 Pharmacological treatment is initiated
with an antipsychotic when diagnosis
is confirmed
7.2 Medication is initiated at the lowest rec-
ommended dose (e.g.. chlorpromazine 50
mg, risperidone 1 mg, haloperidol 1.5
mg, olanzapine 5 mg, fluphenazine History Sheet
decanoate
12.5 mg, etc.) and escalated progressively
7.3 Provision of more than one antipsychot-
ics is justified

2
7.4 Appropriate treatment plan for co morbid
illnesses is devised (if any)
8 APPROPRIATE MANAGEMENT IS 100%
PROVIDED FOR A PATIENT WITH
SCHIZOPHRENIA ACCORDING TO
THE RISK LEVEL ASSESSED
8.1 Patient with high risk situations is man-
aged and admitted
8.2 Patient with high-risk situation who Triangulate
cannot be admitted is sent out with strict the risk
advise for close monitoring from care level with the
takers and more frequent follow up treatment
8.3 Detailed precautionary advises are pro- provided on

2
vided to care taker who are not willing for history Sheet
admission care; these are recorded and
signed
9 APPROPRIATE PSYCHOSOCIAL 100%
MANAGEMENT IS PROVIDED FOR A
PATIENT WITH SCHIZOPHRENIA
9.1 Psycho education is given to patient and/
or care-givers
9.2 Counseling is offered on lifestyle changes
( physical activity, dietary and use of History Sheet
addictive substance )
9.3 Follow-up plan is devised
9.4 Appointment schedule is given
10 APPROPRIATE REFERRAL IS MADE 100%
IF INDICATED FOR A PATIENT
WITH SCHIZOPHRENIA
10.1 The patient is referred when
appropriate resources for the Triangulate
management are not available (e.g., History sheet
ECT, expertise, etc.) with referral
paper
10.2 The patient is referred when complex co
morbid conditions exist and need referral
11 IDENTIFICATION OF THE 100%
PROVIDER IS DOCUMENTED FOR A
PATIENT WITH SCHIZOPHRENIA
11.1 Name and Signature of the provider
is clearly documented on all History sheet
evaluation notes
Total standards met per chart
Percentage

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric
Asso- ciation, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.
Audit Tool: Schizophrenia follow-up care
Facility name
Department/unit
Audit Topic Schizophrenia follow-up care
Aim To improve the quality of clinical care provided to patients with schizophrenia
Objectives To ensure patients with schizophrenia are evaluated properly during follow up
To ensure appropriate risk assessment is done for patient with schizophrenia during follow up
To ensure patients with schizophrenia are managed properly during follow up
Period of Audit
Inclusion All patients with schizophrenia who have been on follow up for more than one year
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient

Actual Perfor-
Data Source

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- Remark
for- against
tion
mance target
1 IDENTIFICATION INFORMATION IS 100%
RECORDED FOR A PATIENT WITH
SCHIZOPHRENIA DURING FOLLOW
UP
1.1 Name
1.2 Age
History
1.3 Sex Sheet (on
1.4 Date of Evaluation each sheet
1.5 MRN of evalua-
tion note)
1.6 Source of information (From patient and
collateral)
2 APPROPRIATE FOLLOW-UP EVAL- 100%
UATION IS CONDUCTED FOR A
PATIENT WITH SCHIZOPHRENIA
DURING FOLLOW UP

2
2.1 Changes in symptoms and signs
from the previous visit are evaluated History
2.2 Emergence of new symptoms and Sheet
signs are looked for
2.4 Changes in level of function of patient
is assessed
2.5 Adherence to medications is assessed History
2.6 Assessment for medication Sheet
adverse effect is done
2.7 Mental status examination is done

2
3 CHANGES IN RISK FOR SUICIDE 100%
AND HOMICIDE ARE ASSESSED FOR
A PATIENT WITH SCHIZOPHRENIA
DURING FOLLOW UP
3.1 Change in risk for suicide and History
homicide are assessed Sheet
4 APPROPRIATE FOLLOW-UP DIAG- 100%
NOSIS IS MADE FOR A PATIENT
WITH SCHIZOPHRENIA DURING
FOLLOW UP
4.1 Symptom control is correctly identified Triangulate
4.2 Disorder progress is correctly deter- history, P/E
mined (e.g., remission status, and investi-
relapse) gation find-
ings with
4.3 Emergence of a new diagnosis, if
diagnosis
any, is correctly identified (revision
on history
or co morbid)
sheet

5 APPROPRIATE FOLLOW-UP TREAT- 100%

MENT AND CARE IS PROVIDED
FOR A PATIENT WITH SCHIZO-
PHRENIA DURING FOLLOW UP
5.1 Dose changes are justified Triangu-
late the
treatment
provided in
5.2 Any switches of medications are justified the previous
visit with
the current
treatment
5.3 Combination of antipsychotics is History
justi- fied sheet
5.4 Adverse effects /side effects are managed Triangulate
if there are any the history
with the
manage-
ment on
history
sheet
5.5 Advice is given on lifestyle changes
(e.g., physical activity, dietary and use
of addictive substances) History
sheet
5.6 Follow up plan is devised
5.7 Appointment schedule is given
6 APPROPRIATE REFERRAL IS 100%
MADE IF INDICATED FOR A
PATIENT WITH SCHIZOPHRENIA
DURING FOLLOW UP
6.1 Patient is referred when appropriate
resources for the management are not Triangulate
available (e.g., ECT, expertise, etc.) History
sheet with
6.2 Patient is referred when complex referral
co morbid conditions exist and paper copy
need referral
7 IDENTIFICATION OF THE PRO- 100%
VIDER IS DOCUMENTED FOR A
PATIENT WITH SCHIZOPHRENIA
DURING FOLLOW UP
7.1 Name and Signature of the provider
History
is clearly documented on all
Sheet
evaluation notes
8 AT LEAST TWO-THIRD FUNCTION- 75%
AL STATUS ACHIEVED WITH IN 9
MONTHS PERIOD AFTER INITIA-
TION OF TREATMENT
Total standards met per chart
Percentage

References

2
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Asso-
ciation, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.
Audit Tool: Depression initial care
Facility name
Department/unit
Audit Topic Depressive disorder initial care
Aim To improve the quality of clinical care provided to patients with depression

2
Objectives To ensure patients with depressive disorders are evaluated properly
To ensure appropriate risk assessment is done for patient with depressive disorders
To ensure patients with depressive disorders are managed properly
Period of Audit
Inclusion criteria All patients with depressive disorders presenting at psychiatry OPD
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Data Source Actual

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
WITH DEPRESSIVE DISORDERS
1.1 Name
1.2 Age
1.3 Sex History Sheet
1.4 Date of Evaluation (on each sheet
of evaluation
1.5 MRN note)
1.6 Source of referral
1.7 Source of information
2 APPROPRIATE PSYCHIATRIC 100%
HISTORY AND MENTAL
STATE EXAMINATION IS
DONE FOR A PATIENT WITH
DEPRESSIVE DISORDERS
2.1 Presence of core sign and symptoms (
low or depressed mood loss of History Sheet
pleasure or interest) are assessed
2.2 Presence of additional sign and
symptoms ( decreased energy, sleep
complaints, problem with appetite
and/or weight, lack of concentration,
psychomotor agitation or retardation,
guilt or worthless feeling, recurrent
thoughts of death) are assessed History Sheet
2.3 Past and current manic episode is
assessed (elated or irritable
mood, excessive happiness, etc)
2.4 Screening for psychoactive
substances use is done
2.5 Screening for general medical Triangulate
condi- tion that may explain the History Sheet
depression is done with lab report
2.6 Functional status is determined
2.7 Duration of symptoms is identified History Sheet
2.8 Symptoms of psychosis are assessed
2.9 Screening for other medical conditions
Triangulate
like HTN, cardiac, DM, neurologic
History Sheet
problems, HIV, Tuberculosis and Cer-
with lab report
vical ca (for females) is done
2.10 Medications the client is using for
treatment of medical condition and
other reasons(e.g. OCP) are recorded History Sheet
and used for decision
2.11 Mental state examination is done
3 APPROPRIATE PHYSICAL EXAM- 100%
INATION IS DONE FOR A PATIENT
WITH DEPRESSIVE DISORDERS
3.1 Vital signs are measured
Blood pressure
Pulse rate History Sheet
Respiratory rate
Temperature
4 RELIVANT INVESTIGATIONS ARE 75%

2
DONE FOR A PATIENT WITH
DE- PRESSIVE DISORDERS
4.1 CBC
4.2 Organ function (LFT, RFT,TFT) Triangulate
History sheet
4.3 Pertinent imaging
with Lab
4.4 HCG in female patients of reproduc- report
tive age
5 APPROPRIATE RISK ASSESSMENT 100%

2
IS DONE FOR A PATIENT WITH
DEPRESSIVE DISORDERS
5.1 Presence of suicidal thought,
plans, intent or/and attempt are
assessed
5.2 History of infanticide or homicide History Sheet
thought, plans, intent, attempt; neglect,
abuse are assessed
5.3 Experience of neglect and abuse
are assessed
6 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PATIENT WITH
DE- PRESSIVE DISORDERS
6.1 Diagnosis is made based on presence
of at least one core sign and symptom
Triangulate
(from 2.1), plus at least four
history find-
additional sign and symptoms (from
ings with the
2.2), plus duration of at least two
diagnosis on
weeks, and exclusion of medical and
history sheet
substance causes and presence
dysfunctionality criteria
7 APPROPRIATE TREATMENT 100%
AND CARE IS INITIATED FOR
A PATIENT WITH DEPRESSIVE
DISORDERS
7.1 Appropriate Pharmacotherapy is Triangulate
initiated the history and
Antidepressant medication is pre- P/E findings
scribed with the treat-
ment started
Antipsychotic medication is added on history
for a patient with psychotic features sheet
7.2 Patient is managed according to the Triangulate
risk level assessed the risk level
Patient with high risk situation is ad- findings with
mitted or referred for inpatient service the treatment
started on
history sheet
Patient with high-risk situation who
cannot be admitted is sent out with Triangulate
strict advise for close monitoring the risk level
from care takers findings with
Details precautionary advices are the treatment
pro- vided to a caretaker who is not started on
willing for admission care; these are history sheet
recorded and signed
7.3 Unnecessary combination of medica-
tions are avoided
No antidepressant combination
provided
Other combinations justified
7.4 Psychosocial management is provided
Psycho education is given to patient
and/or care-givers (e.g.. nature of
illness, management options, course History Sheet
and prognosis, medication adherence,
life style modifications)
Counseling and support about lifestyle
modification is given (e.g., physical
activity dietary and cessation of sub-
stance use)
7.5 Follow up plan is devised
7.6 Appointment schedule is given
8 APPROPRIATE REFERRAL IS 100%
MADE WHEN NECESSARY FOR
A PATIENT WITH DEPRESSIVE
DISORDERS
8.1 Patient is referred when appropriate
resources for the management are not
available (e.g., ECT, In-patient treat- Triangulate
ment, expertise, etc) History sheet
with referral
8.2 Patient is referred when complex paper
co morbid conditions exist and
need referral
9 IDENTIFICATION OF THE 100%

2
PRO- VIDER IS DOCUMENTED
FOR A PATIENT WITH
DEPRESSIVE DISORDERS
9.1 Name and Signature of the provider
is clearly documented on all History Sheet
evaluation notes
Total standards met per chart
Percentage

2
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric
Association, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.
Audit Tool: Depression follow-up care
Facility name
Department/unit
Audit Topic Depressive disorder follow-up care
Aim To improve the quality of clinical care provided to patients with depression during follow up
Objectives To ensure patients with depressive disorders are evaluated appropriately during follow up
To ensure appropriate risk assessment is done for patient with depressive disorders during follow up
To ensure patients with depressive disorders are managed properly during follow up
Period of Audit
Inclusion criteria All patients with depressive disorders who have been on follow-up for at least 6 months post first diagnosis
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Actual Perfor-

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
Data Source per- mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target Remark
and verification for- against
mance target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
WITH DEPRESSIVE DISORDERS
DURING FOLLOW UP
1.1 Name
1.2 Age
History Sheet
1.3 Sex (on each sheet
1.4 Date of Evaluation of evaluation
1.5 MRN note)
1.6 Source of information
2 APPROPRIATE FOLLOW-UP EVAL- 100%
UATION IS DONE FOR A PATIENT
WITH DEPRESSIVE DISORDERS
DURING FOLLOW UP
2.1 Changes in every of symptoms
and signs are assessed

2
2.3 Adherence to treatment is assessed History Sheet
2.4 Change in functional status is assessed
2.5 Medication side effects are assessed
2.6 Presence of ongoing
psychosocial stressors are History Sheet
assessed
2.7 Mental state examination is done
3 CHANGE IN LEVEL OF RISK (SUI- 100%
CIDE , INFANTICIDE, HOMICIDE,

2
ABUSE, NEGLECT) IS ASSESSED
FOR A PATIENT WITH DEPRESSIVE
DISORDERS DURING FOLLOW UP
3.1 Change in level of risk (suicide ,
infanticide, homicide, abuse, History Sheet
neglect) is assessed
4 APPROPRIATE FOLLOW-UP DIAG- 100%
NOSIS IS MADE FOR A PATIENT
WITH DEPRESSIVE DISORDERS
DURING FOLLOW UP
4.1 Symptom control is correctly identified Triangulate his-
4.2 Disorder progress is correctly deter- tory, P/E and
mined (e.g., remission status, investigation
relapse) findings with
4.3 Emergence of a new diagnosis, if diagnosis on
any, is correctly identified (revision history sheet
or co morbid)
5 APPROPRIATE FOLLOW UP TREAT- 100%
MENT AND CARE IS PROVIDED
FOR A PATIENT WITH DEPRESSIVE
DISORDERS DURING FOLLOW UP
5.1 Medication adjustments and switches
are justified
5.2 The need for continued treatment is
justified
5.3 Psychosocial support such as History Sheet
psycho- therapy and counseling
services are given
5.4 Follow up plan is devised
5.5 Appointment schedule is given
6 APPROPRIATE REFERRAL IS MADE 100%
WHEN NECESSARY FOR A PA-
TIENT WITH DEPRESSIVE DISOR-
DERS DURING FOLLOW UP
6.1 Patient is referred When appropriate
resources for the management are not
available (e.g., ECT, In-patient treat- Triangulate
ment, expertise, etc.) History sheet
with referral
6.2 Patient is referred When complex paper copy
co morbid conditions exist and need
referral
7 IDENTIFICATION OF THE PRO- 100%
VIDER IS DOCUMENTED FOR A
PATIENT WITH DEPRESSIVE DIS-
ORDERS DURING FOLLOW UP
7.1 Name and Signature of the provider
is clearly documented on all History Sheet
evaluation notes
8 A PATIENT WITH DEPRESSIVE 75%
DISORDERS ACHIEVED A FUNC-
TIONAL RECOVERY OF 80% WITH History Sheet
IN 6 MONTHS PERIOD AFTER
INITIATION OF TREATMENT
Total standards met per chart
Percentage

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric
Association, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.

2
Audit Tool: Substance use disorder initial care
Facility name
Department/unit
Audit Topic Substance use disorder intial care
Aim To improve the quality of clinical care provided to patients with substance use disorder

2
Objectives To ensure patients with substance use disorder are evaluated appropriately
To ensure appropriate risk assessment is done for patient with substance use disorder
To ensure patients with substance use disorder are managed appropriately
Period of Audit
Inclusion All patients with substance use disorder presenting at psychiatry OPD
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Data Source Actual

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
WITH SUBSTANCE USE DISORDER
1.1 Name
1.2 Age
1.3 Sex History Sheet
1.4 Date of Evaluation (on each sheet
of evaluation
1.5 MRN note)
1.6 Source of referral
1.7 Source of information
2 APPROPRIATE PSYCHAITRIC 100%
HISTORY AND MENTAL STATE
EXAMINATION ARE DONE FOR A
PATIENT WITH SUBSTANCE USE
DISORDER
2.1 Presence of use of the substance in
larger amounts or over a longer period History sheet
than intended is assessed
2.2 Experience of persistent desire or
unsuccessful efforts to cut down or
control the consumption of the sub-
stance is assessed
2.3 Presence of spending great deal of time
in activities necessary to obtain, use or
recover from the effects is assessed
2.4 Presence of craving, or a strong
desire or urge to use the substance
are as- sessed
2.5 Presence of failure to fulfill major
role obligations at work, school, or
home due to substance use is
assessed
2.6 Presence of use of the substance
despite having persistent or recurrent
social
or interpersonal problems caused or
exacerbated by it is assessed
2.7 Presence of giving up or reduction History sheet
of important social, occupational, or
recreational activities due to
substance use is assessed
2.8 Presence of recurrent use in situations
in which it is physically hazardous is
assessed
2.9 Presence of continued use of the
substance despite knowledge of
having a persistent or recurrent
physical or psychological problem
caused or exac- erbated by it is
assessed
2.10 Presence of phenomena of tolerance
is assessed
2.11 Presence of experience of
withdrawal phenomena is assessed
2.12 Functional status is assessed
2.13 Presence of mental disorders such as
depression, bipolar disorder and psy-

2
chosis are assessed
2.14 Presence of liver disease,DM,HTN and
cardiovascular, and respiratory illness Triangulate
are assessed history sheet
2.15 Presence of neurological with investi-
conditions,T- bC, HIV and cervical gation reports
cancer (for female patient) are
assessed
2.16 Mental state examination is done
2.17 Collateral information is gathered or
History sheet
clinician has a plan to gather
collateral history
3 APPROPRIATE RISK ASSESSMENT 100%
IS DONE FOR A PATIENT WITH

2
SUBSTANCE USE DISORDER
3.1 Presence of suicide( intent, plan
and attempt) are assessed
3.2 Presence of homicide( intent, attempt History sheet
and commission) are assessed
3.3 Presence of abuse or neglect is assessed
4 APPROPRIATE LONGITUDINAL 100%
HISTORY OF SUBSTANCE USE DIS-
ORDER IS TAKEN FOR A PATIENT
WITH SUBSTANCE USE DISORDER
4.1 Information is gathered on previous
care received

4.2 Information is gathered on abstinence/

recovery history
History sheet
4.3 Information is gathered on the chal-
lenges for sustaining abstinence
4.4 Specific issues causing relapse (if any)
is assessed
5 APPROPRIATE INFORMATION IS 100%
GATHERED FOR A PATIENT WITH
SUBSTANCE USE DISORDER ON
THE READINESS OF CHANGE
5.1 The level of motivation is assessed
(pre-contemplation, contemplation,
etc)
5.2 Client recognition on the need to quit
or not is assessed History sheet

5.3 Client readiness to quit or not is

assessed
6 APPROPRIATE PHYSICAL EXAMI- 100%
NATION IS DONE FOR A PATIENT
WITH SUBSTANCE USE DISORDER
6.1 Vital signs are measured
Blood pressure
Pulse rate
Respiratory rate
History Sheet
Temperature
6.2 Physical exam of the chest,
cardiovas- cular, abdomen, skin and
the nervous system is done
6.3 Screening for cervical cancer is Triangulate
done for female patient history sheet
with investi-
gation reports
7 RELEVANT INVESTIGATIONS ARE 75%
DONE FOR A PATIENT WITH SUB-
STANCE USE DISORDER
7.1 CBC
7.2 Organ function (LFT including biliru-
bin, RFT) Triangulate
History sheet
7.3 HCG in female patients of
with lab
reproductive age
report
7.4 In tertiary centers urine drug screen is
done
8 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PATIENT WITH SUB-
STANCE USE DISORDER
8.1 The presence of at least two of the Triangulate
above manifestations listed 2.1 to 2.11 history find-
within the previous 12 month period at ings with the
the time of is used for diagnosis diagnosis on
history sheet
9 APPROPRIATE TREATMENT AND 100%
CARE IS PROVIDED FOR A PA-
TIENT WITH SUBSTANCE USE
DISORDER
9.1 Brief intervention is applied
9.2 Motivational enhancement counseling

2
is given to a client who is at the con-
templation stage History sheet
9.3 Use of medicines to assist treatment
is justified
9.4 Counseling and support about lifestyle
modification is given (eg, physical
activity and dietary advice)
History sheet
9.5 Follow up plan is devised
9.6 Appointment schedule is given
10 APPROPRIATE REFERRAL IS 100%

2
MADE WHEN NECESSARY FOR A
PATIENT WITH SUBSTANCE USE
DISORDER
10.1 Patient is referred when appropriate
resources for the management are not
available (e.g., lack of expertise, In-pa- Triangulate
tient management, etc) history sheet
with referral
10.2 Patient is referred when complex paper copy
co morbid conditions exist and
need referral
11 IDENTIFICATION OF THE PRO- 100%
VIDER IS DOCUMENTED FOR A
PATIENT WITH SUBSTANCE USE
DISORDER
11.1 Name and Signature of the provider
is clearly documented on all History sheet
evaluation notes
Total standards met per chart
Percentage

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric
Association, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.
Audit Tool: Substance use disorder follow-up care
Facility name
Department/unit
Audit Topic Substance use disorder follow-up care
Aim To improve the quality of clinical care provided to patients with substance use disorder during follow up
Objectives To ensure patients with substance use disorder are evaluated appropriately during follow up
To ensure appropriate risk assessment is done for patient with substance use disorder during follow up
To ensure patients with substance use disorder are managed appropriately during follow up
Period of Audit
Inclusion criteria All patients with substance use disorder who have been on follow-up for at least 6 months post first diagnosis
Exclusion criteria (where applicable)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Data Source Actual

chart 18
chart 10
chart 11
chart 12
chart 13
chart 14
chart 15
chart 16
chart 17

chart 19
mance

chart 1
chart 2
chart 3
chart 4
chart 5
chart 6
chart 7
chart 8
chart 9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
WITH SUBSTANCE USE DISORDER
DURING FOLLOW UP
1.1 Name
1.2 Age
History Sheet
1.3 Sex (on each sheet
1.4 Date of Evaluation of evaluation
1.5 MRN note)
1.6 Source of information
2 APPROPRIATE COMPRHENSIVE 100%
FOLLOW UP ASSESSMENT IS DONE
FOR A PATIENT WITH SUBSTANCE
USE DISORDER DURING FOLLOW
UP
2.1 Vital signs are measured

2
Blood pressure
History Sheet
Pulse rate
Respiratory rate
Temperature
2.2 Treatment adherence is assessed
(atten- dance)
2.3 Change in substance use behavior
is assessed
2.4 Coping style of patient under stressful

2
situations and craving for substance History Sheet
are assessed
2.5 Change in the level of motivation
for change in substance use
behavior is assessed
2.6 Change in functional status is assessed
3 CHANGE IN LEVEL OF RISK TO SELF 100%
AND OTHERS IS ASSESSED FOR A
PATIENT WITH SUBSTANCE USE
DISORDER DURING FOLLOW UP
3.1 Change in level of risk to self and
History Sheet
others is assessed
4 APPROPRIATE FOLLOW-UP DIAG- 100%
NOSIS IS MADE FOR A PATIENT
WITH SUBSTANCE USE DISORDER
DURING FOLLOW UP
4.1 Symptom control is correctly identified Triangulate
4.2 Disorder progress is correctly deter- history, P/E
mined (e.g., remission status, and investiga-
relapse) tion findings
with diagnosis
4.3 Emergence of a new diagnosis, if
on history
any, is correctly identified (revision
sheet
or co morbid)
5 APPROPRIATE FOLLOW UP TREAT- 100%
MENT AND CARE IS GIVEN FOR
A PATIENT WITH SUBSTANCE USE
DISORDER DURING FOLLOW UP
5.1 Motivational enhancement therapy is
given during each follow up visit
5.2 Counseling on lifestyle modification
is given (eg, advice on physical activity, History Sheet
diet, etc)
5.3 Follow up plan is devised
5.4 Appointment schedule is given
6 APPROPRIATE REFERRAL IS MADE 100%
WHEN NECESSARY FOR A PATIENT
WITH SUBSTANCE USE DISORDER
DURING FOLLOW UP
6.1 Patient is referred when appropriate
resources for the management are not
available (e.g., lack of expertise, In-pa- Triangulate
tient management, etc) History sheet
with referral
6.2 Patient is referred when complex paper
co morbid conditions exist and
need referral
7 IDENTIFICATION OF THE PRO- 100%
VIDER IS DOCUMENTED FOR A
PATIENT WITH SUBSTANCE USE
DISORDER DURING FOLLOW UP
7.1 Name and Signature of the provider
is clearly documented on all History sheet
evaluation notes
8 A PATIENT WITH SUBSTANCE USE 75%
DISORDER ACHIEVED FUNCTION-
AL RECOVERY OF 90% WITH IN 6 History Sheet
MONTHS PERIOD AFTER INITIA-
TION OF TREATMENT
Total standards met per chart
Percentage

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric
Asso- ciation, 2022.
Sadock, B. J., Sadock, V. A., Ruiz, P., & Kaplan, H. I. (2017). Kaplan and Sadock’s comprehensive textbook of psychiatry (10th ed.). Wolters Kluwer.

2
Emergency and Crtical Care Audit Tools
Audit Tool: Triage
Facility name
Department/unit
Audit Topic Emergency Triage

2
Aim To improve the quality of triage care provided for a patient presenting to ED
Objectives To ensure patients’ vital signs are properly measured at triage
To ensure patients are asked for chief complaint at the triage
To ensure patients are evaluated for differential factors at triage
To ensure patient’s triage destination is properly decided
Period of Audit
Inclusion criteria All patients who were admitted to the emergency
Exclusion criteria (where applicable) Patients who were referred to the emergency from OPD or other departments
Instructions Patients who don’t have identification (Mr. and Ms. X)
For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individu- al patient
Actual Perfor-
Data
per- mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria Target Source and Remark
for- against
verification
mance target
1 PATIENT’S BIODATA IS RE- 100%
CORDED UPON PRESENTATION
TO ED
1.1 Name
1.2 Age
1.3 Sex
1.4 Date of triage Triage
paper
1.5 Time of triage
1.6 MRN
1.7 Mode of arrival
2 PATIENT’S CLINICAL CON- 100%
DITION IS ASSESSED UPON
PRESENTATION TO ED
2.1 Chief Complaint is identified Triage
2.2 BP is measured paper
2.3 PR is counted
2.4 RR is counted
2.5 Temperature is measured
2.6 RBS is measured
Triage
2.7 SpO2 is measured paper
2.8 Triage Score is calculated
2.9 Differential Factors are circled
2.10 Triage color is decided
3 ADDITIONAL INFORMATION 100%
IS IDENTIFIED FOR A PATIENT
PRESENTING TO THE ED
3.1 History of Allergy
(Including “None”) Triage
3.2 Triage intervention (Including paper
“None”)
4 IDENTIFICATION OF CARE 100%
PROVIDER IS DOCUMENTED
FOR A PATIENT PRESENTING
TO THE ED
4.1 Name and signature of the triage Triage
personnel is recorded paper
5 PATIENT’S TRIAGE SCORE AND/ 100%
OR DIFFERENTIAL FACTOR
Triage
MATCHES WITH THE TRIAGE
paper
DESTINATION THE PATIENT IS
ALLOCATED TO
Total standards met per chart
Percentage

References
National Integrated Emergency Medicine Training; Federal
Ministry of Health, Ethiopia, 2015
Judith E. Tintinalli, Tintinalli’s Emergency Medicine: A Com-
prehensive Study Guide, 9th ed., McGraw Hill Education, 2020
Ron M. Walls, Rosen’s Emergency Medicine Concepts and

2
Clinical Practice, 9th ed., Elsevier, 2018
Audit Tool: Poisoning
Facility name
Department/unit
Audit Topic Emergency management of poisoning patient
Aim To improve the quality of clinical care provided to a patient presenting to ED with poisoning

2
Objectives To ensure poisoning patients presenting to the ED are resuscitated appropriately
To ensure poisoning patients presenting to the ED are evaluated appropriately
To ensure identification of exact poisoning or toxidrome identification is done in the ED
To ensure appropriate initial treatment is started in the ED
Period of Audit
Inclusion criteria Patients who were treated in the emergency for poisoning with in the study period
Exclusion criteria (where applicable) Patients with diagnosis of alcohol intoxication
Patients who do not have identification (Mr. X, Miss X)
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the indi-
vidual patient
Perfor-
Data Source Actual
mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
PATIENT PRESENTING WITH
POISONING
1.1 Name
1.2 Age
1.3 Sex ED Admis-
1.4 Date of visit sion note
1.5 Time of visit
1.6 MRN
2 APPROPRIATE EVALUATION 100%
AND MANAGEMENT FOR ACUTE
LIFE THREATENING INJURIES IS
DONE FOR A PATIENT PRESENT-
ING WITH POISONING USING
STANDARD POISIONING CARE
PRINCIPLES
2.1 Evaluation of airway patency is
done (airway labeled as clear/patent ED Admis-
or statements such as presence of sion note
secre- tion or presence of foreign
body)
2.2 If patient has secretion secretions
are suctioned out
Triangulate
2.3 Airway management is done if ED Admis-
there are signs of airway sion note
obstruction or GCS ≤ 9 (Oral with order
airway or insertion or supraglottic sheet
device placement or endotracheal
intubation or surgical airway)
2.4 Appropriate breathing evaluation
is made
Oxygen saturation measured
Respiratory rate counted ED Admis-
sion note
Respiratory movement symmetry
assessed
Chest is auscultated
2.5 Oxygen is provided using nasal Triangulate
prong or face mask for patient order sheet
re- quiring oxygen support with medica-
tion sheet
2.6 Ventilation is provided using me- Triangulate
chanical ventilator for patient order sheet
who has indication for intubation with history
sheet
2.7 Blood pressure is measured Triangulate
ED Admis-
sion note
2.8 Pulse rate is measured with V/S
sheet
2.9 IV line is secured: Peripheral Triangulate
percutaneous Intravenous access/ In- ED Admis-
traosseous access/ Venous cut down/ sion note
Central venous access established with order
2.10 NS/RL is administered and/or sheet and

2
vasopressor provided if patient medication
is hypovolemic sheet
2.11 GCS is assessed
ED Admis-
2.12 Pupillary size and reaction sion note
are checked
2.13 RBS is checked Triangulate
order sheet
with investi-
gation paper
2.14 Dextrose given if patient is Triangulate
hypogly- cemic order sheet
with medica-

2
tion sheet
2.15 Decontamination by removing Triangulate
clothes or entire body washing ED Admis-
is done sion note
with order
sheet
3 DETAILED HISTORY TAKEN 100%
AND PHYSICAL EXAMINATION
IS PERFORMED FOR A PATIENT
PRESENTING WITH
POISONING
3.1 Current Sign/symptoms are assessed
3.2 Allergy and Medications history
are assessed
3.3 Past medical and surgical history
is taken
3.4 Last oral intake is identified
3.5 Type and dose of poisoning sub-
stance asked
ED Admis-
3.6 Time of exposure is identified sion note
3.7 Reason of exposure is inquired
3.8 Route of exposure is specified
3.9 Patient is assessed for presence
of additional ingested substance
3.10 Pertinent physical examination relat-
ed to the type of poisoning
substance is performed on every
system
4 RELEVANT INVESTIGATION ARE 100%
DONE FOR A PATIENT PRESENT-
ING WITH POISONING
4.1 CBC Triangu-
4.2 RFT for those with indication late ED
Admission
4.3 LFT for those with indication note with
4.4 Serum electrolyte (Na, K, Mg) investigation
for those with indication paper
4.5 Coagulation profile (PT, PPT, INR) Triangu-
4.6 ECG done for those with indication late ED
Admission
4.7 Additional investigation based on note with
the history and physical examination investigation
is done paper
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PATIENT PRE-
SENTING WITH POISONING
5.1 Specific causative agent/s and severity Triangulate
of poisoning are Identified or If exact the history,
poisoning agent can not be P/Eand
identified, then the toxidrome is diagnosis on
identified. history sheet
5.2 Complications from the poisoning with order
are identified sheet

6 APPROPRIATE TREATMENT IS 100%

PROVIDED FOR A PATIENT PRE-
SENTING WITH POISONING
6.1 Gastric lavage is done for patient Triangulate
who presented within one hour of ED Admis-
sub- stance ingestion in poisoning sion note
cases with indication with Order
sheet
6.2 Substance specific antidote Triangulate
with appropriate dosage is order sheet
initiated if required with medica-
tion sheet
6.3 Dialysis is performed for patient
with phenobarbitone poisoning,
salisalats, metformin, lactic acidosis Triangulate
and val- poric acid poisoning ED Admis-
sion note
6.4 Alkalization with sodium bicarbon- with Order
ate is initiated for patient with D4D, sheet
ASA, metformin and phenobarbitone
poisoning
6.5 Vital sign are assessed at least every
one hour for patients with severe

2
cases
BP
Vital sign
PR sheet
RR
Oxygen saturation(SPO2)
Temperature
6.6 Input output is followed as per Triangulate
order and fluid balance calculated order sheet
with vital
sign sheet
7 APPROPRIATE DISPOSITION IS 100%
MADE FOR A PATIENT PRESENT-
ING WITH POISONING

2
7.1 For patient who is discharged and Triangulate
where suicide attempt has been ED progress
identified consultation with a trained note with
professional has been provided consultation
before discharge and appropriate note with
arrangements are made for psychiat- discharge
ric follow up. Note
7.2 For patient with moderate to Triangulate
severe case, admission to ward or the time of
ICU is done with in 24 hours. patient ar-
rival and the
diagnosis on
ED admis-
sion Note
with the time
of admission
on ED trans-
fer note/ ED
order sheet

7.3 For patient who can not be treated Triangulate

at the facility, appropriate referral the progress
is made as per national standard note with re-
ferral paper
8 IDENTIFICATION OF CARE 100%
PRO- VIDER IS DOCUMENTED
FOR
A PATIENT PRESENTING WITH
POISONING
8.1 Name and signature of the
ED admis-
physician is clearly documented on
sion Note
all ED admission history and P/E
sheets
8.2 Name and Signature of the
ED progress
physician is clearly documented on
Note
all ED progress notes
8.3 Name and signature of the
ED order
physician is clearly documented on
Sheet
all ED order sheets
8.4 Name and signature of the nurse is
ED medica-
clearly documented on all ED
tion Sheet
medi- cation sheets
9 PATIENT DIAGNOSED WITH 80%
POISONING IS DISCHARGED Transfer
FROM THE ED ALIVE (discharged sheet/referral
home, transferred to ward or ICU or sheet
referred to higher care center)
Total met standards per chart
Percentage

References
Lewis Nelson; Goldfrank’s Toxicologic Emergencies, McGraw Hill Education, 11th ed., 2018
Judith E. Tintinalli, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed., McGraw Hill Education,
2020
Ron M. Walls, Rosen’s Emergency Medicine Concepts and Clinical Practice, 9th ed., Elsevier, 2018

2
Audit Tool: Trauma
Facility name
Department/unit
Audit Topic Trauma management in the ED
Aim To improve quality of clinical care provided to trauma patients

2
Objectives To ensure trauma patients presenting to the emergency are appropriately evaluated
To ensure trauma patients presenting to the emergency are appropriately investigated
To ensure trauma patients presenting to the emergency are appropriately treated
To ensure trauma patients presenting to the emergency are appropriately disposed
Period of Audit
Inclusion criteria All trauma patients aged 14 and above, treated in the emergency with-in the study period
Exclusion criteria (where applicable) Patients who arrived 24 hours after sustaining trauma
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
Perfor-
Data Source Actual
mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria Target and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT PRE-
SENTING WITH TRAUMA
1.1 Name
1.2 Age
1.3 Sex Patient’s ED
Admission
1.4 Date of visit
note
1.5 Time of visit
1.6 MRN
2 APPROPRIATE EVALUATION AND 100%
MANAGEMENT FOR ACUTE LIFE
THREATENING INJURIES IS DONE
FOR A PATIENT PRESENTING
WITH TRAUMA USING STANDARD
TRAUMA CARE PRINCIPLES
2.1 Evaluation of airway patency is done
(airway labeled as clear/patent or
state- ments such as presence of
secretion, presence of foreign body or
injury to the face is written)
2.2 If patient has secretion secretions
are suctioned out
2.3 If foreign body is present it is removed
2.4 Airway management is done (Oral air-
way or insertion or supraglottic device
placement or endotracheal intubation
or surgical airway)
2.5 Evaluation of cervical stability is
done for patients with GCS score of
15.
2.6 Cervical collar is secured for cervical
injury suspected patients (Use
NEXUS criteria) Triangulate
2.7 Appropriate breathing evaluation Patient ED
is made Admission
Note, Order
Oxygen saturated measured
Sheet, Pro-
Respiratory rate counted cedure Note,
Respiratory movement symmetry Medication
assessed Sheet and
Vital Sign
Chest is auscultated
Sheet
2.8 Oxygen is provided using nasal
prong or face mask
2.9 Ventilation is provided using bag
valve mask for patients with low GCS
or apneic patients until definitive
airway is secured
2.11 Ventilation is provided using
mechan- ical ventilator for patients
who have indication for intubation
2.12 Needle thoracostomy is done for pa-
tients with suspected tension pneumo-
thorax

2
2.13 Chest tube is inserted for patient with
open/closed pneumothorax and/or
hemothorax and/or flail chest
2.14 Evaluation for active external
bleeding is done
2.15 Active bleeding is stopped if present
2.16 If tourniquet is used to stop bleeding,
tourniquet time is clearly recorded on
chart
2.17 Blood pressure is measured
2.18 Pulse rate is measured

2
2.19 IV line is secured: Peripheral
percuta- neous
2.21 Intravenous access/ Intraosseous ac-
cess/ Venous cut down/ Central
venous access is established
2.22 NS/RL is administered and/or blood Triangulate
transfused if patient is hypovolemic Patient ED
2.23 Pelvic stability is checked Admission
2.24 Pelvic stabilization is done if unstable Note, Order
Sheet, Pro-
2.25 GCS is assessed cedure Note,
2.26 Pupillary size and reaction are checked Medication
2.27 Motor preference is checked Sheet and
Vital Sign
2.28 RBS is checked Sheet
2.29 Dextrose is given if patient is
hypogly- cemic
2.31 Log-roll is done
2.32 Patient is evaluated for presence
of wounds
2.33 Fractures are immobilized if present
2.34 Digital rectal examination is done
2.35 Spinal stability is checked
2.36 Bed side ultrasound is done
(FAST/ eFAST)
3 DETAILED HISTORY TAKEN AND 100%
PHYSICAL EXAMINATION PER-
FORMED FOR A PATIENT PRE-
SENTING WITH TRAUMA
3.1 Signs and symptoms related to
the trauma are assessed
3.2 Presence of drug or medication Patient’s ED
allergy is assessed Admission
Note
3.3 History of chronic medication usage
is assessed
3.4 Past medical and surgical history
is taken
3.5 Time of last oral intake is identified Patient’s ED
Admission
3.6 Events: time of incident, accounts of Note
the event, injuries to other people are
inquired
3.7 Vital signs are measured
BP
PR
RR Patient’s Vital
Sign Sheet
Oxygen saturation(SPO2)
Temperature
Pain score
3.8 Head to toe physical examination is Patient’s ED
done (HEENT, R.S, CVS, ABD,MSK, Admission
GUS, CNS) Note
4 RELEVANT INVESTIGATION ARE 80%
DONE FOR A PATIENT PRESENT-
ING WITH TRAUMA
4.1 Imaging of the affected body part
is done Triangulate
4.2 Trauma series is done: C-spine, the history,
Chest, Thoracolumbar & pelvic -XR P/E findings
for polytrauma patient with diag-
nosis on the
4.3 CBC, Blood group & Rh, Cross- patient’s ED
match, urine HCG (for reproductive Admission
age female patient) are determined Note with in-
4.4 RFT and serum electrolytes are done vestigations
for severe TBI, crush injury and papers
shock patients
5 APPROPRIATE DIAGNOSIS IS 100%
MADE FOR A PATIENT PRESENT-
ING WITH TRAUMA
5.1 All injuries are appropriately Triangulate
diagnosed and written including the history
complications from the injury/injuries findings with

2
5.2 Type of injury is recorded (RTA, the diagno-
falling down accident, gun shot etc.) sis on ED
Admission
Note
6 APPROPRIATE TREATEMENT IS 100%
PROVIDED FOR A PATIENT PRE-
SENTING WITH TRAUMA
6.1 Wound cleaning, suturing, and dressing
are done for patient with wounds Triangulate
6.2 Supportive management is started the history,

2
Urinary catheter inserted for immobile P/E findings
and GCS < 14 patients on ED
admission
GI prophylaxis (polytrauma patients note with the
and severe TBI patients, patients order on the
with NG-tube in-situ) Order Sheet
Pain management is provided
6.3 Consultation to concerned depart- Triangulate
ments is made within 1 hr the time of
patients first
evaluation
with the time
the con-
sultation is
made on the
consultation
Paper
7 APPROPRIATE PATIENT DISPO- 100%
SITION IS DONE FOR A PATIENT
PRESENTING WITH TRAUMA
7.1 Adequate discharge care is provided
for patient who is discharged to home
care
Advise is provided on danger signs
Discharge
Appropriate wound care referrals Note
is given
Pain management prescription is
provided
Follow up appointment is given
7.2 For patient who is admitted either to Triangulate
ward, OR ICU, admission is provided the time of
with-in 24 hours. patient ar-
rival and the
diagnosis on
ED admis-
sion Note
with the time
of admission
on ED trans-
fer note/ ED
order sheet

7.3 For patient who can not be treated at Triangulate

the facility, appropriate referral is the progress
made as per national standard note with re-
ferral Paper
8 IDENTIFICATION OF CARE 100%
PRO- VIDER IS DOCUMENTED
FOR
A PATIENT PRESENTING WITH
TRAUMA
8.1 Name and signature of the physician
ED admis-
is clearly documented on all
sion Note
admission history and P/E sheets
8.2 Name and Signature of the physician
ED progress
is clearly documented on all progress
Note
notes
8.3 Name and signature of the physician ED order
is clearly documented on all order Sheet
sheets
8.4 Name and signature of the nurse is
ED medica-
clearly documented on all medication
tion Sheet
sheets
9 A PATIENT PRESENTING WITH 4%
TRAUMA DIED WITHIN 48
HOURS OF HOSPITAL ARRIVAL
TO THE HOSPITAL (CAN BE WITH
IN OR OUT SIDE THE
EMERGENCY DE- PARTMENT)

2
Total standards met per chart
Percentage

References
Judith E. Tintinalli, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed., McGraw Hill Education, 2020
Ron M. Walls, Rosen’s Emergency Medicine Concepts and Clinical Practice, 9th ed., Elsevier, 2018
Audit Tool: ICU
Facility name
Department/unit
Audit Topic Routine care in the ICU
Aim To improve the quality of routine clinical care provided to patients admitted to critical care unit

2
Objectives To ensure optimal nutritional support is provided for patients admitted to the ICU
To ensure timely and appropriate patient mobilization is provided for patients admitted to the ICU
To ensure appropriate pain evaluation and management is done for patients admitted to the ICU
To ensure VAP preventive methods are practiced for patients admitted to the ICU
To ensure optimal physician care is provided for patients admitted to the ICU
To ensure optimal nursing monitoring is provided for patients admitted to the ICU
Period of Audit
Inclusion criteria Patients on routine ICU care
Exclusion criteria (where applicable) Patients who were admitted for ≤ 72 hours
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individu- al patient
For monitoring section, use data from the first 7 days of admission of the patient to ICU
Perfor-
Data Actual
mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria Target Source and perfor- Remark
against
Verification mance
target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A PATIENT
ADMITTED TO THE ICU
1.1 Name Triangulate
1.2 Age Admission
Note with
1.3 Sex Order
1.4 MRN Sheets with
Nursing
Follow-up
Sheets
2 OPTIMAL NUTRITIONAL SUP- 75%
PORT IS PROVIDED FOR A PA-
TIENT ADMITTED TO THE
ICU
2.1 Nutrition is started within 24 hours
of admission
2.2 Feeding order is
appropriately written
Order sheet
Energy and protein content
Volume of feeding
It is updated daily
2.3 Nutritional status is assessed Nutritional
on admission assessment
sheet /ICU
Admission
Paper
2.4 Residual volume is determined
before every meal Nursing
Follow-up
2.5 Feeding is given as per order
Sheet
2.6 NG tube care is given
3 APPROPRIATE AND TIMELY PA- 80%
TIENT MOBILIZATION IS DONE
FOR A PATIENT ADMITTED TO
THE ICU
3.1 Patient position is changed every Triangulate
2 hours Progress
3.2 Limb physiotherapy is done Notes with
Order
3.3 DVT prevention method (anticoagu- Sheets with
lation or compressive stoking) is Nursing
used Follow Up
Sheet
4 APPROPRIATE PAIN AND AG- 100%
ITATION EVALUATION AND
MANAGEMENT IS PROVIDED
FOR A PATIENT ADMITTED TO
THE ICU
4.1 Pain assessment is done every
4 hours
4.2 Pharmacological pain management is Triangu-
provided for patient who is identified late Order
to have pain Sheets with

2
Nursing
4.3 Sedation score is calculated every 4 Follow Up
hours. Sheets
4.4 Sedation management is provided
for patient with RAAS more than
one
5 APPROPRIATE VENTILATOR 80%
ASSOCIATED PNEUMONIA (VAP)
PREVENTION METHODS ARE
APPLIED FOR PATIENT ADMIT-
TED TO ICU
5.1 Head of the bed is elevated
more than 30 degree

2
Nursing
5.2 Mouth care is given every 4 hours Care Sheet
5.3 Closed suctioning is done
5.4 Spontaneous weaning trial is Triangu-
done daily late Order
Sheets with
Nursing
Care Sheet
6 OPTIMAL PHYSICIAN CARE IS 100%
PROVIDED FOR A PATIENT AD-
MITTED TO THE ICU
6.1 Admission evaluation is done Physician
Admission
Note
6.2 Base line investigations are sent on Triangulate
admission (CBC, UA, RFT, LFT, Physician
serum electrolytes (sodium, chloride, Admission
potassium, calcium) and serum Note with
albumin) admission
order Sheet
with in-
vestigation
papers
6.3 Patient is followed by physicians Triangu-
and progress notes are written at late Order
least daily Sheets with
6.4 Order sheets are revised daily Progress
Notes
7 OPTIMAL NURSING MONITOR- 90%
ING IS PROVIDED FOR A PA-
TIENT ADMITTED TO THE ICU
7.1 Vital signs are measured at least
one hourly
BP
PR
RR
SpO2
Temperature
7.2 RBS is measured at least every 6
hourly
7.3 For patient on mechanical ventilator,
ventilator parameters are checked
every 1 hourly
7.4 All of the patient’s fluid intake Nursing
is recorded Follow-up
7.5 Patient’s fluid intake is added Sheet
(calcu- lated) at the end of each shift
7.6 Patient’s urine output is measured
at least every 4 hourly
7.7 Patient’s insensible loss is calculated
at the end of each shift
7.8 All of the patient’s fluid output
(urine output, output from different
drains and insensible loss) are added
(calculated) together at the end of
each shift
7.9 Input-output balance is calculated at
the end of each shift
8 IDENTIFICATION OF CARE 100%
PROVIDER IS DOCUMENTED
FOR A PATIENT ADMITTED TO
THE ICU

2
8.1 Name and signature of the Admission
physician is clearly documented on History
all admis- sion history and P/E sheet
sheets
8.2 Name and Signature of the
Progress
physi- cian is clearly
note sheet
documented on all progress

2
notes
8.3 Name and signature of the
physician is clearly documented on Order sheet
all order sheets
8.4 Name and signature of the nurse is
Medication
clearly documented on all medica-
sheet
tion sheets
9 PATIENT DIED WHILE BEING 35%
MANAGED IN THE ICU
Total standards met per chart
Percentage

References
Marino’s, The ICU Book, 4th ed. Paul. L. Marino, Lippincont William & Wilkins,
2014
Irwin and Rippe’s, Intensive Care Medicine; 8th ed. Wolters Kluwer, 2018
Hall, Schmidt, and Wood’s, Principles of Critical Care, 4th ed. McGraw Hill Educa-
tion, 2015
Audit Tool: Burn
Facility name
Department/unit
Audit Topic Burn patient management in the emergency room
Aim To Improve the quality of clinical care provided to burn patients
Objectives To ensure burn victims presenting to the emergency are evaluated appropriately
To ensure burn victims presenting to the emergency are investigated appropriately
To ensure burn victims presenting to the emergency are treated appropriately
To ensure burn victims presenting to the emergency are disposed appropriately
Period of Audit
Inclusion criteria All moderate and severe burns (patients with burn injuries fulfilling admission criteria either to ward or burn unit) patients
aged 14 and above treated in the emergency department with-in the study period
Exclusion criteria (where applicable) Patients who sustained their burn injury >24 hrs. before arrival to the ED
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individ- ual patient
Perfor-
Data Source Actual
Target

mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria and verifica- perfor- Remark
against
tion mance
target
1 IDENTIFICATION INFORMA- 100%
TION IS RECORDED FOR A
PATIENT PRESENTING WITH
BURN
1.1 Name
1.2 Age
1.3 Sex Patient ED
Admission
1.4 Date of visit
Note
1.5 Time of visit
1.6 MRN
2 APPROPRIATE EVALUATION 100%
AND MANAGEMENT FOR
ACUTE LIFE THREATENING
INJURIES IS DONE A PATIENT

2
PRESENTING WITH BURN
2.1 Decontamination is done if the
patient has chemical burn
2.2 Evaluation of airway patency is
done (airway is clear/patent or
presence of secretion, presence of
foreign body or injury to the face
or presence of soot inside nostrils

2
is evaluated)
2.3 If patient has secretion
secretions are suctioned out
2.4 If foreign body is present it
is removed
2.5 Airway management is done (Oral
airway or insertion or supraglottic
device placement or endotracheal
intubation or surgical airway) if Triangulate
airway patency is compromised Patient ED
2.6 Evaluation of cervical stability is Admission
done for patient with GCS score Note, Order
of 15 and concomitant other Sheet, Pro-
physical trauma is identified cedure Note,
Medication
2.7 Cervical collar is secured for cervi-
Sheet and
cal injury for patient with concomi-
Vital Sign
tant physical trauma
Sheet
2.8 Appropriate breathing evaluation
is conducted
Oxygen saturation measured
Respiratory rate counted
Respiratory movement symmetry
assessed
Chest is auscultated
2.9 Oxygen is provided using nasal
prong or face mask for patient
with SpO2 < 90%
2.10 Ventilation is provided using me-
chanical ventilator for patient who
have evidence of severe
inhalational burn
2.11 Appropriate interventions are done
for other suspected/identified trau-
ma on the respiratory system (Chest
tubes for concomitant pneumo-
thorax and/or hemothorax, needle
thoracostomy done for tension
pneumothorax patients)
2.12 Blood pressure is measured
2.13 Pulse rate is counted
2.14 IV line is secured: Peripheral
percutaneous Intravenous access/
Intraosseous access/ Venous cut
down/ Central venous access
established
2.15 Immediate fluid resuscitation with
Ringer’s Lactate is started if the
patient is in shock state Triangulate
2.16 GCS is calculated, pupillary size Patient ED
and reaction are checked, motor Admission
preference is checked and RBS is Note, Order
measured Sheet, Pro-
cedure Note,
2.17 Dextrose is given if patient is Medication
hypo- glycemic Sheet and
2.18 Log-roll is done Vital Sign
2.19 Total burn surface area is Sheet
calculated using either rule of 9 and
Lund and Browder’s chart for
adults and pal- mar surface method
for pediatric patients
2.20 Assessment for presence of
eshcar at any site is done
2.21 If eshcar is present, eshcarotomy
is done
2.22 Patient is evaluated for presence of
compartment syndrome if circum-
ferential burn is diagnosed on distal
extremities

2
2.23 Bed side ultrasound is done
(FAST/ eFAST) for patient with
concomi- tant physical trauma
3 DETAILED HISTORY AND 100%
PHYSICAL EXAMINATION
PERFORMED FOR A PATIENT
PRESENTING WITH BURN
3.1 Detailed history of the burn inci-
dent is recorded (Duration of burn,
the type of burn experienced by

2
the patient; if the burn occurred in
closed or open area; other materials
that were burned during the inci-
dent; if it was electrical burn, the
voltage of line and entry site)
3.2 Patient’s current complaint Patient’s ED
is recorded Admission
3.3 Past medical and surgical Note
history is taken
3.4 History of food or medication
allergy is taken
3.5 Current medications patient is on
medications are identified
3.6 Time of last meal the patient took
is identified
3.7 Vital signs are retaken
(Time specified)
Blood pressure
Pulse rate Patient’s
Respiratory rate Vital Sign
Sheet
Oxygen saturation(SpO2)
Temperature
Pain score
3.8 Head to toe physical examination
is performed
Detailed report of burned areas
with full description of size,
depth and local complications is Patient’s ED
written Admission
Note
Pulse rate counted
Respiratory rate is counted
Oxygen saturation(SpO2) measured
Temperature measured
4 RELEVANT INVESTIGATION 100%
ARE DONE FOR A PATIENT
PRESENTING WITH BURN
4.1 Baseline CBC, RFT and serum Triangulate
elec- trolytes (Na, K) are Patient ED
determined Admission
4.2 ECG is done for electrical Note with
burn patient investigation
papers and/
4.3 Other investigations as per indica- or investiga-
tion are done tion summa-
ry

5 APPROPRIATE DIAGNOSIS IS 100%

MADE FOR A PATIENT PRE-
SENTING WITH BURN
5.1 Primary diagnosis is written Triangulate
5.2 Severity of burn injury is identified the history
and P/E
5.3 TBSA is calculated findings
5.4 All degrees of burn the with the
patient sustained are specified diagnosis on
5.5 Diagnosis of additional Patient ED
observed conditions and admission
complications is made Note with
ED admis-
sion Order
Sheet
6 APPROPRIATE TREATMENT IS 100%
PROVIDED FOR A PATIENT
PRESENTING WITH BURN
6.1 Wound care is done regardless
of the severity of burn injury
6.2 Tetanus prophylaxis is provided
for the patient whose tetanus Triangulate
immuni- zation status is not up-to- Patient’s ED
date Admission
6.3 Patients with partial thickness burn Note with
>10% or full thickness burn >2%, ED Order

2
patients with burns to the face, Sheet with
major joints, perineum or hands, Medication
patients with high voltage electri- Sheet
cal burns or lightening or patients
with chemical burns are kept in the
emergency until admission/referral
is facilitated
6.4 For severe burn patient (TBSA >
20% for adults or > 10% for chil-
dren except for 1st degree burns,
burns complicated by trauma or
inhalational injury, chemical burn
and high-voltage electrical burn)
appropriate monitoring is done

2
Order is written to put patient on
cardiac monitor
BP measured every 1hr
PR measured every 1hr
RR is measured every 1hr
Patient is put on continuous oxygen
saturation monitor and finding
recorded every 1 hr.
Temperature is recorded every 1 hr
Urine output is measured every 1hr Triangulate
Patient’s ED
Pain score is determined every 4hrs
Admission
6.5 For non-critical burn patient, ap- Note with
propriate monitoring is done ED Order
BP measured every 4hrs. Sheet with
PR measured every 4hrs. Medication
Sheet
RR measured every 4hrs.
Urine output is measured every
4hrs.
Pain score is determined every 4hrs.
6.6 Parkland formula is used for cal-
culation of fluid resuscitation if
the patient presents within 24
hours of burn incident (except for
electrical burn patients)
6.7 Appropriate fluid loss estimation
and replacement is made for electri-
cal burn patient
Loss is estimated using urine output
Urine out put is measured every
one hour
Fluid loss is replaced based on
Triangulate
urine output with Ringers lactate
Patient’s ED
6.8 Standing dose analgesia is provided Admission
6.9 Topical agents are ordered to Note with
be used during wound care ED Order
Sheet with
6.10 Temperature target is determined
Medication
and means of preventing hypother-
Sheet
mia is planned/ordered
6.11 Patient is monitored for additional
observed conditions and complica-
tions of burn
Urine color, urinalysis, and serum Triangulate
creatinine for patient with high progress
voltage burn (rhabdomyolysis) note with
investigation
papers
Airway condition for patient with
suspected inhalational injury and
facial and neck burn Progress
Signs and symptoms of note
compart- ment syndrome for
patient with circumferential burn
injuries
6.12 Consultation to the burn unit is Triangulate
made (Time of consultation spec- Patient’s ED
ified) Admission
Note with
ED Order
Sheet with
Consulta-
tion Sheet
7 APPROPRIATE PATIENT DIS- 100%
POSITION IS DONE FOR A
PATIENT PRESENTING WITH
BURN
7.1 For patient with partial thickness Triangulate
burn >10% or full thickness burn Patient’s ED
>2%, patient with burns to the Admission

2
face, major joints, perineum or Note with
hands, patient with high voltage ED Order
electrical burns or lightening or Sheet with
patient with chemical burns; Transfer/re-
patient is admitted or referred to ferral sheet
burn unit
8 IDENTIFICATION OF CARE 100%
PROVIDER IS DOCUMENTED
FOR A PATIENT PRESENTING
WITH BURN
8.1 Name and signature of the phy-
ED admis-
sician is clearly documented on
sion History
all ED admission history and P/E

2
sheet
sheets
8.2 Name and Signature of the
ED progress
physi- cian is clearly
note sheet
documented on all ED progress
notes
8.3 Name and signature of the physi-
ED order
cian is clearly documented on all
sheet
ED order sheets
8.4 Name and signature of the nurse
ED medica-
is clearly documented on all ED
tion sheet
medication sheets
9 PATIENT DIAGNOSED WITH 2% Triangulate
BURN DIED WHILE BEING admission
MANAGED IN THE EMER- note with
GENCY WITHIN 24HOURS progress
OF ADMISSION TO ED note and
discharge
note.
Total standards met per chart
Percentage

References
Advanced Burn Life Support Course, Provider’s Manual;
American Burn Association; 2018
Judith E. Tintinalli, Tintinalli’s Emergency Medicine: A Com-
prehensive Study Guide, 9th ed., McGraw Hill Education, 2020
Ron M. Walls, Rosen’s Emergency Medicine Concepts and
Clinical Practice, 9th ed., Elsevier, 2018
Nursing and Midwifery Audit Tool
Audit Tool: Nursing and Midwifery Care
Facility name Bele Gesgar Hospital
Department/unit Nursing and midwifery Departement
Audit Topic Nursing and midwifery care( patients who are admitted) (IPD)
Aim To improve the quality of nursing care provided to patient admitted to wards
Objectives To ensure appropriate nursing and midwifery assessment and diagnosis is made for admitted patients
To ensure appropriate nursing and midwifery intervention plan is designed and implemented for admitted patients
To ensure appropriate nursing and midwifery progress evaluation is done for admitted patients
Period of Audit 4th Quarter of 2015
Inclusion criteria All admitted patients
Exclusion criteria (where applicable) Mothers who are on labour and emergency, patients who were admitted for less than 24 hrs.
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
indi- vidual patient
For nursing progress assessment and care section use data from the first 7 days of admission of the patient to inpatient (if
the patient stays more than seven days please review only the last seven days of progress )
Actual Perfor-
Data Source per- mance

chart10
chart11
chart12
chart13
chart14
chart15
chart16
chart17
chart18
chart19
chart1
chart2
chart3
chart4
chart5
chart6
chart7
chart8
chart9
No Standards/criteria Target Remark
and Verification for- against
mance target
1 DEMOGRAPHIC AND IDEN- 100%
TIFICATION INFORMATION
IS RECORDED FOR A PATIENT
ADMITTED TO THE WARD
1.1 Name
1.2 Age
1.3 Sex
1.4 Address
Nursing/mid-
1.5 MRN wifery care
1.6 Bed number plan
1.7 Date of visit
1.8 Time of visit

2
2 APPROPRIATE NURSING/ MID- 100%
WIFERY ASSESSMENT IS DONE
FOR A PATIENT ADMITTED TO
THE WARD
2.1 Personal details of patient
is recorded
2.2 Details of patient’s support
is recorded
2.3 Subjective data of patient
taken (based on Gordon’s

2
functional model )
Health Perceptions and Manage-
ment Pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Nursing/mid-
Activity-Exercise Pattern wifery care
Cognitive-Perceptual Pattern plan
Sleep-Rest Pattern
Self-Perception and Self-
Concept Pattern
Roles and Relationships Pattern
Sexuality-Reproductive Pattern
Coping and Stress
Tolerance Pattern
Values and Belief Pattern
2.4 Vital signs are measured
according to the order
BP
Triangulate
PR
order sheet
RR with Vital sign
Temperature sheet
PSO2
Pain score
2.5 Past medical history is taken
2.6 Objective data of patient is
taken (based on Gordon’s
functional model )
Health Perceptions and Manage- Nursing/mid-
ment Pattern wifery care
plan
Nutritional-Metabolic Pattern
Elimination Pattern
Activity-Exercise Pattern
Cognitive-Perceptual Pattern
Sleep-Rest Pattern
Self-Perception and Self-
Concept Pattern
Roles and Relationships Pattern Nursing/mid-
wifery care
sexuality-Reproductive Pattern
plan
Coping and Stress
Tolerance Pattern
Values and Belief Pattern
2.7 Subjective and objective data Triangulate
is correctly summarized the objective
and subjective
data with the
summary on
nursing/mid-
wifery care plan
3 APPROPRIATE NURSING/MID- 100%
WIFERY DIAGNOSIS IS MADE
FOR A PATIENT ADMITTED TO
THE WARD
3.1 Identification information of the
patient is recorded
Full name
Age
Nursing/mid-
Sex wifery care
MRN plan
Ward
Bed number
3.2 Nursing diagnosis is Triangulate the
formulate based on revised diagnosis on
NANDA list nursing/mid-
wifery care
plan with
NANDA list

2
3.3 The actual nursing diagnosis go Triangulate
with the nursing assessment Prob- the objective
lem, Etiology and Signs(PES) and subjective
3.4 The potential nursing data with the
diagnosis go with the nursing diagnosis on
assessment Problem and nursing/mid-
wifery care plan

2
Etiology (PE)
4 APPROPRIATE NURSING 100%
MIDWIFERY CARE PLAN IS
DESIGNED FOR A PATIENT
ADMITTED TO THE WARD
4.1 Identification information of the
patient is recorded
Full name
Age Nursing/mid-
Sex wifery care plan
(Plan section)
MRN
Ward
Bed number
4.2 Goal and expected outcome out- Nursing/mid-
lined wifery care plan
(Expected out-
come section
4.3 Nursing intervention designed Nursing/mid-
wifery care plan
(Intervention
section)
4.4 Nursing intervention is consistent Triangulate
with expected goal and outcome the planned
intervention
with goal
and outcome
5 APPROPRIATE CARE PLAN 100%
IS IMPLEMENTED FOR A
PATIENT ADMITTED TO
THE WARD
5.1 Identification information of the
patient is recorded
Full name
Age
Nursing/mid-
Sex wifery care
MRN plan
Ward
Bed number
5.2 Implemented intervention cor- Triangulate
relates with problem is the problem
identified identified with
the intervention
on nursing/
midwifery care
plan
5.3 Intervention is implemented ac- Triangulate the
cording to the plan implemented
interven-
tion with
the planned
intervention
on nursing/
midwifery care
plan
6 APPROPRIATE EVALUTION 100%
OF THE PLAN IS DONE FOR
A PATIENT ADMITTED TO
THE WARD
6.1 Progress is monitored at least daily
Current patient status is assessed
Planned goals are achieved Nursing/mid-
Newly aroused or resolved prob- wifery care
lems are entered in problem index plan
list/diagnosis
7 APPROPRIATE MEDICATION 100%
MANAGEMENT IS DONE FOR
A PATIENT ADMITTED TO

2
THE WARD
7.1 Medication is administered as per
the physician order
Name of patient Triangulate or-
Drug name der sheet with
medication
Dose
sheet
Route

2
Frequency
8 ADMITTED PATIENT IS HAN- 100%
DOVERED PROPERLY BE-
TWEEN NURSES
8.1 Patient is handover by using
standardized format/book between
each shift
8.2 Necessary information about the
patient is communicated to the
next shift
Full name
Age
Sex Patients han-
MRN dover format/
book
Ward
Bed number
Current diagnosis
Activities performed
Procedures performed
Pending investigations
New patient complaint
9 PROPER HEALTH EDUCATION 100%
IS PROVIDED FOR A PATIENT
ADMITTED TO THE WARD
9.1 Health education is provided daily Nursing/mid-
wifery care plan
or any standard
health educa-
tion form
10 IDENTIFICATION OF 100%
PROVID- ER IS
DOCUMENTED FOR A
PATIENT ADMITTED TO THE
WARD
10.1 Name and signature of the attend-
ing nurse is clearly documented Vital Sign sheet
on all vital sign sheets
10.2 Name and signature of the attend-
Medication
ing nurse is clearly documented on
sheet
all medication sheets
10.3 Name and signature of the attend-
Nursing/mid-
ing nurse is clearly documented on
wifery care
all vital care plan forms
plan
11 PATIENT DEVELOPED BED 0% Exclude
SORE DURING WARD patients who
STAY developed bed
sore prior to
admission
Total standards met per chart
Percentage

References
Ethiopian hospital service transformation guideline volume 1, 2016
Health sector transformation in quality, 2016
Nursing/midwifery comprehensive client assessment format

2
Surgical-Anesthesia care Audit Tool
Audit Tool: Surgical-Anesthesia Care
Facility name
Department/unit
Audit Topic Peri-operative care (patients who under went surgery in the past one week)

2
Aim To improve the quality of general peri - operative care provided to surgical patients
Objectives To ensure patients who under go surgery have appropriate pre- admission anesthesia care
To ensure patients who under go surgery have appropriate pre operative preparation
To ensure patients who under go surgery have appropriate intraoperative care
To ensure patients who under go surgery have appropriate post operative care
To ensure patients who under go surgery have appropriate post operative care
Period of Audit
Inclusion criteria All patients who have undergone surgery under general, spinal or regional anesthesia (use OR registry as a source to iden-
tify population)
Exclusion criteria (where applicable) Surgical patients that have not had surgery (due to failed intubation ,spinal or regional anesthesia )or had minor surgery
Instructions If completed give ‘yes’ if not give ‘no’ give NA if the criterion does not apply to the individual patient
For the monitoring section, use the data form the first ten days after surgery
Actual Perfor-
Data Source
per- mance
No Standards/criteria Target and verifica- Remark
for- against
tion
mance target
1 IDENTIFICATION INFORMATION 100%
IS RECORDED FOR A SURGICAL
PATIENT
1.1 Name
1.2 Age
1.3 Sex
Pre-anesthet-
1.4 Date of Evaluation ic evaluation
1.5 MRN sheet
1.6 Surgical Diagnosis
1.7 Surgical procedure
2 PRE-ANESTHETIC EVALUATION IS 100%
DONE FOR A SURGICAL PATIENT
BEFORE ADMISSION USING A PRE-
FORMED PRE-ANESTHESIA SHEET
OR CHECKLIST
2.1 Appropriate history is taken ( history
of present illness , previous anesthesia
history of Allergy ,current medication
, substance use, last meal and other
pertinent facts related to the clinical pre anesthetic
condition of the patent evaluation
2.2 Relevant physical examination is sheet
done ( Vital signs , airway ,
conjunctiva or mucosal membrane,
CVS, Chest and other relevant organ
and system perti- nent to the clinical
condition)
2.3 Relevant investigations are done(CBC, Triangulate
Blood group and RH and other perti- history and
nent investigation related to the P/E findings
clinical condition) with order
sheet, with
investigation
report and
pre anesthetic
evaluation
sheet
3 APPRORIATE ASSESSMENT IS 100%
MADE FOR A SURGICAL PATIENT
BASED ON PREANSESHTETIC
EVALUATION
3.1 Fitness to surgery is determined (Fit/ Triangulate
Unfit) the history
3.2 Risk stratification is made based P/E and
on ASA classification (ASA 1-5 +/- investigatio
E) n findings
with order
sheet and pre
anesthetic
evaluation
sheet
4 APPROPRIATE DECSION IS MADE 100%
FOR A SURGICAL PATIENT BASED
ON PREANSESHTETIC ASSESMENT

2
4.1 For fit patient appropriate Triangulate
anesthesia plan is formulated the history,
4.2 For unfit patient appropriate optimiza- P/E, and
tion plan is formulated investigatio
n findings
with order
sheet and pre

2
anesthetic
evaluation
sheet
5 ADEQUATE PRE-OPERATIVE 100%
PREPARATION IS MADE FOR A
SURGICAL PATIENT
5.1 Consent is taken (name of the patent
,date , card number , type of
anesthesia and its risk , type of
procedures and
its risk, name of anesthesiologist Consent form
and or anesthetists, name of the
surgeon and signature, Patient or
guardian signature, Two Witnesses’
name and signature)
5.2 Patient is kept NPO prior to surgery Triangulate
(for elective cases) order sheet
with nursing
carry out
sheet/nursing
progress note
5.3 Antibiotics are given when applicable Triangu-
in 30min before surgery late order
sheet with
medication
sheet/nursing
progress note
5.4 Procedure type is indicated in the History sheet/
chart order sheet
5.5 Procedure site indicated (side to
History sheet
be operated and site mark)
5.6 Medications are revised or Pre schedul-
initiated according to patients’ ing checklist
condition or triangulate
order sheet
and nursing
progress note
5.7 Blood is prepared for procedures that Pre schedul-
are estimated to have > 500ml of ing checklist
blood loss or Triangu-
late order
sheet wit
cross match
paper/nurs-
ing progress
note
5.8 Psychological support is provided Pre schedul-
5.9 Body care instruction is given to ing checklist
the patient or nursing
progress note
6 SURGICAL SAFETY OF PATIENT IS 100%
MAINTAINED AT ALL TIMES DUR-
ING OPERATIONS
6.1 Operation room readiness is assessed
OR readiness
using OR readiness checklist (all
checklist
fields are completed)
6.2 Patient is handover to the OR team
Handover
with adequate information using hand-
checklist
over checklist (all fields are complete)
6.3 Intra operative patient safety is
main- tained using WHO surgical
safety checklist (all fields are WHO sur-
completed) gical safety
Sign in checklist
Time out
Sign out
7 APPROPRIATE PATIENT MON- 100%
ITORING IS PROVIDED FOR A
SURGICAL PATIENT DURING
OPERATION
7.1 Heart rate is measured every five
min- ute and recorded every ten
minute
7.2 Blood pressure is measured every five
minute and recorded every ten minute

2
Anesthesia
7.3 Respiratory rate is measured every record sheet
five minute and recorded every ten
minute
7.4 Oxygen saturation is measured contin-
uously and recorded every ten minute
7.5 Rhythm is assessed continuously
and recorded every ten minute
7.6 Temperature is measured continuously
and recorded every ten minute
7.7 Blood loss is estimated at least
every one hour
7.8 Urine out put is monitored at least
every one hour

2
7.9 Anesthesia record sheet is fully
com- plete
Date
Induction time and incision time
Patient name and MRN
Anesthetist /Anesthesiologist name
Name of surgeon
Baseline Vital sign Anesthesia
Baseline Hg and Blood group& RH record sheet
Type of anesthesia given
Anesthesia medications
ETT type and size used
Medical gases used
Procedure note for regional
anesthesia or other invasive
procedures
Iv accesses
Fluid administered
Total time of anesthesia and surgery
Reversal drugs provided when
appli- cable
8 APPROPRIATE POST-OP CARE 100%
IS PROVIDED FOR A SURGICAL
PATIENT
8.1 Operation proceedings are document-
ed
Patient identification (Patient’s
Name, age, sex, Date, MRN ) Operation
Operating team (name of operation note
Surgeon, Assistant, Anesthesiologist
/ anesthetist, Scrub nurse, Circulating
nurse)
Procedure profile (Pre-operative
diagnosis, Post-operative diagnosis,
Indication for the procedure when the
pre -operative diagnosis is different
form the indication ,Procedure Name)
Operation
Procedure details (Type of anesthesia note
Patient position, Skin preparation,
Incision, Exposure and exploratory
findings, The procedure (what is done)
Accidents or unexpected happenings
and their management
8.2 Patient is handover to the PACU team
PACU hand-
with adequate information using hand-
over checklist
over checklist (all fields are complete)
8.3 Post operative care to be carried out in
the PACU is clearly communicated
Fluid Order
Oxygen order – flow rate, using what
device, for how long
Analgesia Order
Positioning Order Anesthesia
Medication for nausea/vomiting recording
sheet- back
Monitoring order (vital sign urine out
side
put, consciousness level)
Danger signs/inform when/
Other medications to be given, if any
(e.g. antihypertensive)
Whom to contact in case of emergency
– name and phone
8.4 Post operative care to be carried out in
the ward is clearly communicated
Name Ward/Bed Number Date and
time
Duration of NPO/Dietary initiation
Order sheet
Frequency of v/s check

2
Fluid to be administered
Any Medication to be given
Wound care order
8.5 Patient is monitored and cared in the
PACU appropriately as per
anesthetist or anesthesiologist order
RR and Respiratory effort as per order
SpO2 as per order Triangulate
HR as per order Anesthesia

2
recording
BP as per order sheet (back
Temperature as per order side) with
Pain assessment score as per order PACU fol-
low-up sheet/
Fluid administered as per order PACU Vital
Oxygen administered as per order sign sheet
Analgesia administered as per order
Positioning made as per order
Medication administered as per order
8.6 Patient is discharged from recovery to PACU fol-
a general ward having satisfied low-up sheet/
discharge criteria scoring tool
8.7 Patient is monitored and cared in the
ward appropriately as per surgeon’s Triangulate
order order sheet
with nursing
Kept NPO/Dietary initiation made as progress note
per order
V/s monitored as per order Triangulate
order sheet
with Vital
sign sheet
Fluid administered as per order Triangulate
Medications given as per order order sheet
with medica-
tion sheet
Wound care carried out as per order Triangulate
Order sheet
with nursing
progress
note/medica-
tion sheet
8.9 Patient’s progress is assessed at least Progress note
daily thorough out their stay (date and on continua-
time specified) tion sheet
8.10 Patient is actively assessed for surgical Progress note
site infection on continua-
tion sheet/SSI
surveillance
tool
8.11 Patient who developed SSI is Progress note
managed accordingly on continua-
tion sheet
9 APPRORIATE DISCHARGE CARE 100%
IS PROVIDED FOR A SURGICAL
PATIENT UPON DISCHARGE
9.1 Discharge decision is made (return
for follow-up, referral, home)
9.2 Discharge summary is written (Card
Number, Name, Age, Sex, Admission
Date, Discharge Date, Discharging
physician, Pre Op diagnosis, Post Op
diagnosis, Procedure done, Pt Dis-
charge condition, Hospital stay
course summery, Medication given,
Lab re- sults, Imaging results,
Discharge plan, Follow up plan, Discharge
Wound care, Physical activity advice, summary
Dietary advice)
9.3 Appropriate counseling is provided
Medications the patient will take
at home
Information about When, Where and
Whom to contact for follow-up
How to take care of the wound if
wound is present
Physical activity, Diet and Hygiene
9.4 Appropriate patient linkage is made
Next appointment to surgical OPD is Triangulate
given if the plan is to follow the decision with

2
patient in the facility appointment
date on the
discharge
summary and
referral
Referral is provided if the patient Triangulate
needs further treatment in another decision on
facility the discharge
summary
with referral
paper
10 IDENTIFICATION OF PROVIDER IS 100%
DOCUMENTED FOR A SURGICAL
PATIENT
10.1 Name and signature of the anesthesiol- Pre-anesthet-
ogist/anesthetist is clearly documented ic evaluation
on Pre-anesthetic evaluation sheet sheet
10.2 Name and signature of the Anesthesia Anesthesia
provider is clearly documented on the recording
anesthesia recording sheet sheet
10.3 Name and signature of the surgeon
Operation
is clearly documented on the
note
operation note
10.4 Name and signature of the anesthesiol- Anesthesia
ogist/anesthetist is clearly documented recording
on the transfer note sheet back
side
10.5 Name and signature of the physician
Order sheets
is clearly documented on all order
sheets
10.6 Name and Signature of the
Progress
physician is clearly documented on
notes
all progress notes
10.7 Name and signature of the nurse is
Medication
clearly documented on all medication
sheets
sheets
10.8 Name and signature of the nurse is Discharge
clearly documented on discharge sheet
sheet
11 SURGICAL PATIENT’S LENGTH OF 80%
HOSPITAL STAY DID NOT EX-
TENDED BEYOND THE SIX DAYS
Total standards met per chart

2
Percentage

References
National Per operative guideline 2022
Annex
Annex 1 List of Contributors

Mr. Abebaw
Ayele DPCD MoH- Ethiopia
Psychologist
[Link] Alemayehu
MPH, PhD DPCD MoH-Ethiopia

Mr. Addisu
Ashango Bsc, Menilik II Referral Hospital
Midwife
Dr. Aida Kebede
MD, Psychiatrist Eka Kotebe General Hospital

[Link] Abebe
MPH, MSC DPCD MoH-Ethiopia

Dr. Ananya Abate

Tikur Anbassa Specialized Hospital
MD, Anesthesiology and critical care specialist
[Link] Solomon
MD, OB-GYN Yekatit 12 Hospital Medical college

Dr. Aschalew Worku

Tikur Anbassa Specialized Hospital
MD, Pulmonary and Critical Care physician

Dr. Ataklitie Baraki

Alert Comprehensive Specialized
MD, Consultant General and Plastic & Reconstructive Hospital
Surgeon
[Link] Demtse
MD, Neonatologist Tikur Anbassa Specialized Hospital

Dr. Asrat Habtegiorgis

MD, Psychiatrist [Link] Hospital Millennium Medical
College

[Link] Legesse
BSc, BA, Msc, IA HSQD MoH-Ethiopia

277
Dr. Berhane Redae
HSQD MoH-Ethiopia
MD, Consultant Endoscopy surgeon
Dr. Beza Girma
MD EICCD MoH-Ethiopia

Dr. Dereje Assefa

DPCD MoH-Ethiopia
MD, Psychiatrist, MPH
Dr. Desalegn Bekele
MD HSQD MoH-Ethiopia

Dr. Desalegn
Tegabu MD, MPH, IHI/HFIP
IA
[Link] Mitiku
BSc, Public Health HSQD MoH-Ethiopia
Officer
Dr. Eyob
Gebrehawariyat MD, WHO
MPH
Mr. Ftalew
Dagnew BSc, MPH HSQD MoH-Ethiopia

Dr. Gelawdiwos
Shashe MD, General Zewditu Memorial Hospital
surgeon
Dr. Hassen
Mohammed MD, MPH HSQD MoH-Ethiopia

Mr. Henok
Hailu MSc HSQD MoH-Ethiopia

Dr. Hilina
Tadesse MD, [Link] Hospital Millennium Medical
Pediatrician College

[Link] Admasu
Clinical Psychologist Eka Kotebe General Hospital

278
Dr. Kalkidan Tilahun
AaBET Hospital
MD, Emergency Medicine and Critical Care Physician

Dr. Kibrom
Haile MD, Ammanuel Specialized Mental
Psychiatrist hospital

Dr. Maedot
Tadesse MD, St. Peter specialized hospital
Internist
[Link] Abayneh
MD, Neonatologist [Link] Hospital Millennium Medical
College

Mahlet Asayehegne
BA, MPH CSD MoH-Ethiopia

Dr. Mariamawit Asfaw

MD, OB-GYN [Link] Hospital Millennium Medical
College

Dr. Medhin
Kassa MD HSQD MoH-Ethiopia

Dr. Menbeu Sultan [Link] Hospital Millennium Medical

MD, Emergency Medicine and Critical Care Physician College

Dr. Merhawit Abadi

MD, Pediatrician [Link] Hospital Millennium Medical
College

Dr. Muajub Bullo

MD, Internist Tirunesh Bejing General Hospital

[Link] Adefres
MD, OB-GYN, MPH MCH directorate MoH-Ethiopia

Dr. Muluken
Tesfaye MD, [Link] Hospital Millennium Medical
Psychiatrist College

[Link] Melke
MD, OB-GYN Gandhi Memorial Hospital

279
Dr. Mussie
Gebremichael MD, MPH DPCD MoH-Ethiopia

Dr. Ruth Woldeyohannes

MD, Pediatrician Zewditu Memorial Hospital

Sofia Seid
MSc, ICCMH DPCD MoH-Ethiopia

Dr. Tariku Bahiru

Yekatit 12 Hospital Medical College
MD, Emergency Medicine and Critical Care Physician

Dr. Taika
Alemu MD EICCD MoH-Ethiopia

Mr. Tinsae
Bekele BSc, Zewditu Memorial Hospital
Anesthetist

Sr. Tiruwork Akile

CSD MoH-Ethiopia
R.N, Public health professional (M& E of Psychology)

[Link] Tadesse
BSc, Surgical nurse Zewditu Memorial Hospital

[Link] Gudayu
BSc, MPH Tirunesh Bejing General Hospital

Dr. Yared Boru Alert Comprehensive Specialized

MD, Emergency Medicine and Critical Care Physician Hospital

280
Annex 2 Clinical audit proposal form
Department

Audit Lead
Position Tel

E-mail Address:

New audit: ☐
Re-audit:☐

Uses MoH developed audit standards and criteria(if audit topic is national priority)
Evidence Base/Reference standards used to develop criteria (for audit topics out of national priority)

Audit Title:
Aim
Objectives:

2
Why are you proposing to conduct this audit? How is the topic chosen or prioritized
What standards will you be auditing against? Please attach a copy of the relevant standard(s) to the submission

2
Is this a re-audit? Yes ☐ No ☐ If Yes, have previous audit’s actions been implemented?

Audit Start Date... (Dd/mm/yy) .........................................................................

Data collection to be completed by (Dd/mm/yy ).........................................

Planned presentation at QIT Meeting date (Dd/mm/yy )............................................................

Planned presentation and quality committee Meeting date (Dd/mm/yy )................................................

Audit completion date (not including any action plan dates) (Dd/mm/yy )...................................................

Audit sample size:

Time period to be assessed: From: To:
Please attach Data Collection Proforma and Target Standards

Describe the audit tool you intend to use? Please attach a copy of the audit tool to the submission
Public and Patient Involvement
Applicable: ☐ Not applicable: ☐

If applicable indicate the patient group to whom the audit standards apply to:
Please indicate how patients and/or relatives/caregivers are to be involved in the audit:
Identification of audit topic ☐ Review/Dissemination of results ☐

Audit design ☐

Assistance with carrying out the audit ☐

Input into Action Plan ☐
Evaluation of audit findings ☐

If this audit affects anyone outside your specialty/department, please list those affected below and attach all relevant supporting
correspondence.

INTERNAL (within EXTERNAL (outside the facility)

the facility)

2
Multi-disciplinary audit team/stakeholders (All participants must be listed)
Team/divi-
Name Job title Telephone and email
sion

2
Confidentiality: The use of clinical audit data should follow. Code of practice for undertaking scientific research or studies using patient’s
information. Yes ☐
Resource Implications
Please indicate below the assistance you require from the QI unit
 Assistance with audit topic prioritization

 Assistance with development of criteria

 Assistance with capacity building of QIT members

 Assistance with data analysis relevant to the clinical audit

 Assistance with problem prioritization for intervention

 Assistance with designing interventions

Please tick ( maybe more than one)
Is this audit linked to a risk to the facility, patient, staff, or visitor Yes ☐ No ☐
Is this audit a result of a previous or potential complaint Yes ☐ No
☐ Is the audit linked to high mortality and/or morbidity yes ☐ No ☐
Does the audit have a resource implication Yes ☐ No ☐

Please tick if this audit links to any /all Outcomes as below( maybe more than one)
Domain 1. Preventing people from dying prematurely
Domain 2. Enhancing quality of life for people with long term conditions

Domain 3. Helping people to recover from episodes of ill health or following injury
Domain 4. Ensuring that people have a positive experience of care.
Domain 5. Treating and caring for people in a safe environment and protecting them.
them from avoidable harm

The departmental head must sign below confirming that the Head of Department is aware of, and supports this audit
proposal. SIGNED:
PRINT NAME: Date

2
Annex 3 Clinical audit project registration and monitoring form
T-On track, D- Delayed, C- completed, A-Abandoned
Date audit proposal submitted
Expected date of audit completion

2
Audit Status (T, D, C, A)
Audit lead
wk1 wk 2 wk 3 wk4 wk5 wk 6 wk 7 wk8 wk9 wk10 wk11 wk12 wk13 wk14 Support provided by the QI unit
Phas
one
e
phase two
phase
three
Annex 4: Clinical audit finding reporting template
Title of the audit
Date of report
Department/specialty Re audit date
Audit lead Name Job title

Key stakeholders Names Department

Background & aim: Say why the audit was done. Per-
haps a problem had been identified? Statement of what
the project is trying to achieve:

Standard

Methodology:
State

 Chosen population  How to sample selected

 Retrospective or prospective

2
 Sample size

 Describe tool used

Results:

2
(State the results. Start with total number (n=).
Data may be presented visually (graphs, tables)

Conclusion: (List key points that flow from results)

Recommendation: (bullet point prioritized problems

and change ideas/interventions to be tested)