E024 Development of the musculoskeletal therapies documentation quality standards audit tool

Background/Aims A number of service standards and frameworks are available for musculoskeletal (MSK) clinicians to use to support their clinical practice, and most with some reference to documentation standards and expectations. There have been significant developments in screening questioning, assessment and treatment strategies, patient-centredness, care pathways and service delivery in musculoskeletal practice, but documentation of inflammatory screening is one key area that is frequently an omission in practice. Previous standards or documentation audit checklists have not incorporated a visible evidenced ‘asked and cleared’ approach, particularly the required screening of inflammatory disease, serious and other specific pathology as part of a standard MSK consultation and its documentation, along with the need to evidence other aspects and developments in contemporary MSK practice. Methods The musculoskeletal therapies documentation quality standards audit tool has been developed to bring together existing publications and contemporary clinical practice into one tool to support quicker, less detailed/high-level or in-depth review and evaluation of the quality of musculoskeletal clinical practice and healthcare documentation. The tool encompasses the Chartered Society of Physiotherapy (CSP) Musculoskeletal physiotherapy service standards (2022) which describe eight quality standards to aid high-quality delivery of musculoskeletal physiotherapy services in the public and independent sector. Practice expectations from the Musculoskeletal Core Capabilities Framework for first point of contact practitioners (2018) and Rheumatology Physiotherapy Capabilities Framework (2021) are incorporated, along with recommendations from the CSP Quality Assurance Standards for physiotherapy service delivery (2012), Health and Care Professions Council (HCPC) Standards of Proficiency (2023), and Standards of conduct, performance and ethics (2024). The audit tool is designed to be used in conjunction with other relevant competency frameworks, clinical guidelines, specialty-specific practice and documentation expectations, and local policies and procedures which may be relevant to apply in the evaluation context. Results The audit tool has been piloted and received extensive external review. It is available to all musculoskeletal therapists working across all services and practice settings. Paper and electronic records can be audited. The tool should be used in conjunction with the extensive supporting supplementary information and guidance. Feedback shows ease of use. It is appropriate for all levels of clinical practice. The audit tool acknowledges the variability between job roles, including those working in Advanced Practice and First Contact roles, levels of experience and specialty services and incorporates the option to indicate where a standard is not applicable (N/A) if required. Conclusion The tool aims to provide an evidence-based documentation audit tool to evaluate the quality of patient healthcare records in adult musculoskeletal settings and to support and drive high quality practice and enable audit results to be used to demonstrate quality, or guide training and supervision needs where there are gaps found regarding clinical practice or documentation quality. Disclosure H. Chambers: None. C. McCrum: None.