Training activity information
Details
Audit documentation for a clinical system or key clinical infrastructure and make suitable recommendations
Type
Developmental training activity (DTA)
Evidence requirements
Evidence the activity has been undertaken by the trainee.
Reflection on the activity at one or more time points after the event including learning from the activity and/or areas of the trainees practice for development.
An action plan to implement learning and/or to address skills or knowledge gaps identified.
Considerations
- Local, national, international guidelines and legislation
- Software as a medical device
- Lifecycle management for data protection and cyber security measures
- Documented roles and responsibilities
- Warrantied environment and qualified medical device environment
- Installation environment
- Remote support arrangements
- Change control arrangements
- Quality assurance programmes
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What do you need to know before embarking on this audit? This might include understanding the specific clinical system or infrastructure, relevant regulations, and audit procedures.
- What do you anticipate you will learn from this experience? Consider the specific insights you hope to gain regarding documentation practices, identification of areas for improvement, and the process of making recommendations. Think about what you already know about clinical systems, infrastructure, and documentation.
- What actions will you take in preparation for this experience? Will you discuss the audit process with your training officer? Will you review any existing audit guidelines or documentation for similar systems? Consider possible challenges you might face during the audit (e.g., incomplete documentation, technical jargon) and think about how you might handle them. Identify how you feel about embarking on this training activity.
In action
- As you examine the documentation, what specific steps are you taking? Why are you reviewing these particular documents in this order?
- What decisions are you making about what to include in your audit and what to potentially overlook?
- Which parts of the audit process feel straightforward based on your prior experience, and where do you need to think more deliberately?
- How effective do you feel your current approach is in identifying key areas for improvement? What difficulties are you encountering in understanding the documentation or the system it describes?
- What new insights are you gaining about clinical systems and their documentation as you proceed? How does this relate to what you already know about audit processes or clinical infrastructure?
- If you encounter unclear or missing information, what alternative ways could you try to gather the necessary details? Would seeking clarification from a colleague or supervisor be beneficial at this point? Are the recommendations you are considering within the scope of your role?
On action
- Summarise the key aspects of the documentation you audited, the process you followed, and the recommendations you made.
- What did you learn about the structure and content of clinical system documentation? How did you develop your skills in identifying areas for improvement and formulating recommendations? Were there any unexpected findings or challenges during the audit? What did you learn from these? How will the insights from this audit inform your future interactions with clinical system documentation?
- What areas of documentation auditing do you need to develop further? How can you apply your learning to future audits or reviews of clinical systems? What are your next steps in terms of refining your recommendation skills? Do you require any further resources or guidance on clinical system documentation or auditing processes?
Beyond action
- Have you revisited the documentation you audited and the recommendations you made? How does your current understanding of clinical systems and infrastructure compare to your understanding then? Have you discussed audit processes with colleagues and gained new perspectives?
- How has the experience of conducting this audit and formulating recommendations influenced your approach to reviewing other documents or processes in your current practice? Have the skills you developed, such as attention to detail and critical thinking, been transferable?
- What transferable skills did you develop through this activity? What further actions can you take to enhance your auditing and recommendation skills for future practice?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Review and prepare appropriate documentation for clinical information systems. |