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HCET Home > On-line Training > RVIPP Self Study Manual: Chlamydia > 8. Quality Assurance
8. Quality Assurance
Each state within Region V may have different procedures regarding chart audits. Please consult your state health department for further details. Each clinic should incorporate Chlamydia trachomatis (CT) components into their quality assurance audit. A review and follow-up of the two most current data reports and 25 charts (or 10%, whichever is less) will provide most of the information needed to ascertain if the CT testing, treatment, and referral is meeting clinic standards. This review should include the following elements:- Documentation of risk assessment history and education
- Compliance with clinic screening criteria for testing
- Documentation of test result, follow-up, and treatment, all being completed in a timely manner
- Informed consent for tests and treatment obtained
- Appropriate treatment prescribed
- Documentation of treatment or referral for sex partner(s)
Review of Systems Through Reports
On a quarterly basis, review and analyze test results which include positive, negative, unsatisfactory and inconclusive. Investigate the reasons for unsatisfactory and inconclusive test results and document recommended methods for improvement. Review the quarterly data quality assurance reports indicating missing data elements on laboratory and behavioral questionnaire forms (sentinel sites). Identify problem areas and document recommended methods for improvement.Checklist for Chlamydia Testing, Treatment and Patient Counseling/Education
Specimen Collection
- New staff must be trained in specimen collection and adequacy prior to independently collecting specimens.
Periodically
- Time yourself while rotating the swab in the endocervical canal (swab should be in canal for the time period specified on the manufacturer insert).
- Watch the specimen collection video.
- Have another experienced clinician observe your performance and give you feedback.
Ask yourself
- Do I know the protocol for use of culture and when it is appropriate to use?
- Do I always clean the exocervix?
- Do I always rotate the correct swab in the correct site?
- Do I check to see that the swab is in the tube and the cap securely fastened?
- Do I check to see that the name or unique identifier is on the transport tube and that it matches the laboratory requisition form?
- Do I verify the patient risk history? Is it documented? Do I check out the inconsistencies with the client (e.g. never had sex but has three children)?
- Do I test within the clinic’s screening criteria? Do I know the criteria?
- Do I notify patients of infection within the time frame of my clinic’s protocol?
- Do I adhere to the CDC STD Treatment Guidelines for client treatment?
- Do I take the time to explain the treatment plan to the client adequately? Do I encourage questions? Is the plan in writing for the client to take with her/him? Do I document the referral?
- Do I stress the importance of treating sex partners and offer referrals for their examination and treatment?
- Do I discuss risk reduction and other prevention measures which the client believes (s)he can implement to avoid acquiring a STD in the future?
- Do I complete the laboratory requisition form in readable script?
- Do I ensure the client of confidentiality regarding his/her records and partner referral process?
Remember: If you didn’t document it, it didn’t happen.
All staff working as part of the CT prevention program should have documented CT training pertaining to their area of expertise. Refer to the appendix for staff checklist. Identified training needs resulting from the review of reports and chart audits may be met through the state CT program. Contact your state training representative for more information on training programs that are offered to clinic sites. Please contact your state health department for more information regarding training opportunities.
