COPE® FOR MALE CIRCUMCISION SERVICES - EngenderHealth

COPE for Male Circumcision Services
Client Record-Review Checklist for Male Circumcision Services
Site: _______________________ Reviewer: _______________________ Date: _______________________
This checklist is for staff to determine whether key information is being documented in client records. Select the records for 10 male
circumcision (MC) clients at random for review. Place a checkmark in the appropriate box if the item in the checklist was recorded on
the client’s record; put N/A if the item is not applicable to the client. Comments and clarifying remarks should be made in the space
provided in the table or at the end of this form.
Before using the checklist, compare the items in the checklist with your health care setting’s record form(s). Consider if any important
items are missing from your service setting’s forms, whether there is a need to update your record form(s), or whether any items are
missing from the checklist and need to be added.
For each client record, look for the information specified in the Checklist Item column. If the information has been recorded, write an
“x” or a checkmark () in the corresponding space on the checklist. When each item on the checklist has been reviewed against 10
individual records, note the number of boxes left blank and record it in the column labeled Total Answered Negatively.
Review the data collected in the above checklist. Any negative responses to a checklist item suggest there is room for improvement.
Consider the answers to the following questions when reporting back to the group and making recommendations for the Action Plan:
Was any key information consistently missing from the client records
■ What could be the root cause
■ What are some possible solutions
Checklist Item 1 2 3 4 5 6 7 8 9 10
Total
Answered
Negatively Remarks
Client Profile
Client identification
information (name, age,
sex, residential/postal
address, and telephone or
other contact information,
registration number)
Emergency contact person
(name, relationship,
residential/postal address,
telephone or other contact
information)
(continued)
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