Documentation, Quality Assurance, and Clinical Governance
Domain 9: Documentation, Quality Assurance, and Clinical Governance
This domain tests accurate records, audit, incident reporting, and use of evidence to improve practice.
Core rules
- Document contemporaneously: indication, consent, device type, size, and lot, site, ultrasound findings, number of attempts, operator, complications, tip confirmation, dressing, and patient education.
- A record is a legal document. Use objective terms; avoid blame, speculation, or retrospective alterations. Correct errors with a single line, date, time, and signature.
- Audit metrics: first-attempt success, overall success, arterial puncture, CLABSI or CRBSI, phlebitis, occlusion, extravasation, unplanned removal, dwell time, and documentation completeness.
- Governance: report incidents and near misses; review trends; update protocols; ensure competency assessment and supervision; feed back results without punitive blame.
- Use validated definitions and denominators so comparisons are meaningful.
Worked example
A unit’s PICC CLABSI rate rises. Reasoning: do not conclude “bad technique” from one case. Audit insertion bundle compliance, dressing compliance, hub disinfection, and line days; review each case against definitions; then target the failing step and re-audit.
Traps
Documenting after the shift from memory; omitting failed attempts; not reporting near misses; using audit as punishment; and comparing rates with different denominators.