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THE CLINICAL AUDIT REPORT FORMAT By Dr.Mahboob Khan Phd

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Healthcare consultant
Healthcare consultant

The document outlines the key components and structure that should be followed when writing a clinical audit report. It provides examples of templates that divide the report into sections including: introduction, methods, results, discussion, conclusions, recommendations, and quality improvement plan. The report aims to be clear, concise, and follow a logical progression by using plain English and structured formatting like IMRAD. Visual aids like tables and graphs should be used where possible to clearly present results.

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1 THE CLINICAL AUDIT REPORT FORMAT BY DR.MAHBOOB KHAN PHD The clinical audit report should:  Be simple and clear.  Be written in plain English.  Use a structured, systematic approach, for example, IMRAD (introduction, method, results and discussion which would include recommendations and an agreed quality improvement plan).  Present descriptive statistics graphically where possible  Make sense and follow a logical progression.  Be easy to understand – the report should be written in such a way that it could be understood by a colleague from a different discipline. A good report will make even a complex issue understandable to all. Layout of report The audit report should follow a standard audit report template. Examples SAMPLE TEMPLATE FOR CLINICAL AUDIT REPORT  Introduction Explain the reasoning why the audit was undertaken. Outline when the audit undertaken and how many people/items were surveyed. Outline the aims and objectives of the audit.  Method and Sample Briefly explain the method used and how the sample was chosen. This section should include enough detail to allow anyone re-auditing to use the same approach and methodology. It should include: Who was involved; what type of data collection tool or scale was used; any difficulties experienced; timescales and any expectations.  Results There should be no commentary in this section. Anonymity should be heeded i.e. don’t refer to specific people. Where possible use visual aids such as tables or charts. All tables and figures should have a title and be understood without reference to the text. Be consistent with data presentation, e.g. decimal places, percentages, format.  Discussion This section should not contain any new data. It should draw on the results and make careful interpretation of the findings. Compare the results to other audits. Discuss the strengths and weakness of the audit, are there any discrepancies? Discuss the meaning of the findings and possible implications for health care professionals.  Conclusion and recommendations Use this section to summarise. Put forward recommendations for change, for example, better documentation, training requirements, change of practice. Recommendations should be realistic and achievable.
2 Suggest areas for further works and plans for re-audit if appropriate.  Quality improvement plan The quality improvement plan is a fundamental part of the audit, without it the audit is not effective and has just wasted time, money and effort. The audit loop is completed by developing and implementing the quality improvement plan, use bullet points to keep it short and to the point. The quality improvement plan should identify the person/s responsible for each action. Plan a date for re-audit.  Acknowledgements All those who helped should be mentioned  References Should be numbered or in alphabetical order.  Appendices It may be appropriate to include a copy of the data collection form Another version of a template for a clinical audit report is provided on the next page.
3 SAMPLE TEMPLATE FOR CLINICAL AUDIT REPORT (VERSION 2) Title of Audit: For office use: audit number Date of report: Department/Speciality: Re-audit date: Audit lead/author: Job title: Service provider: Job title: Key stakeholders: Names: Department/ Speciality: Background & aim: Say why the audit was done. Perhaps a problem had been identified? Statement of what the project is trying to achieve: Standard: Methodology: State  Chosen population  How sample selected  Retrospective or prospective  Sample size  Describe tool used Results: (State the results. Start with total number (n=). Data may be presented visually (graphs, tables)
4 Conclusion: (List key points that flow from results) Recommendation: (bullet point action plan-with review date and initials of person in charge of implementation) A report must be written up for each Clinical Audit done. This is the official record of what has been done, which can be returned to in future years. Title This should be the same as the title on the proforma. Background & aim(s) of the audit (Introduction) This is essentially narration, clarifying why the audit was done. For example, was the project prompted by an identified local problem or concern? The background should explain the rationale for doing the audit. Summarise the evidence base for the audit topic, giving any references at the end. If a team was convened to undertake this audit, say how this was organised and who was involved. This will explain what the project is trying to achieve and should have been identified before the audit commenced. Standards Clinical audit must measure against standards, guidelines or benchmarks of some sort, these should be identified and where they come from (the source and strength of evidence). State if the intention was to set standards at the end of the project and if so, which aspects of care those standards pertain to. Methodology State the chosen population for this study (for example, "patients referred to the one-stop breast clinic for suspected cancer") and then to say how the sample was selected the sample for the audit, specifying whether a retrospective or prospective approach was used (for example, for a prospective audit, "the first 100 patients referred to the clinic starting from 1/10/04", or for a retrospective audit, "all patients seen at the outpatient clinic during July "). Describe how these patients were identified, the sample size, the time period, and clarify how this was calculated or agreed upon. The data collection method should also be stated, for example, "Data was collected from patients' case notes using a data collection sheet or a query was run in ICT. List who was responsible for data collection, when this was done, and mention briefly the method of data input (if appropriate) and analysis. Results The number of subjects (for example, patients) included in the audit is the initial 'n' number. If data is incomplete, explain why, for example, it might not be possible to find every set of patient notes. How data is analysed depends upon the question/s to be answered. Ensure to include the number and percentage of cases meeting each criteria of the standard, making it clear what number is been taken a percentage of as the 'n' number may change at different points of the report, for example, 45/50 (90%) for criterion A and 81/90 (90%) for criterion B. Conclusions List the key points that flow from the audit results - use bullet points and avoid long paragraphs. Ensure conclusions are supported by the data, or if the data points to no firm conclusions, say so - don't make claims that are not supported by the evidence. Make objective, factual statements, not subjective ones, i.e. don't say "it is obvious that... “or "clearly, what is happening is ... " Recommendations & Quality Improvement Plan Recommendations for change should be made. Make sure these are realistic and achievable. A quality improvement plan (action plan) should be agreed saying what changes will be implemented, who will be responsible for carrying them out and when this will be done. If appropriate (i.e. changes are to be made), set a date for a re-audit to complete the audit cycle.

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THE CLINICAL AUDIT REPORT FORMAT By Dr.Mahboob Khan Phd

  • 1. 1 THE CLINICAL AUDIT REPORT FORMAT BY DR.MAHBOOB KHAN PHD The clinical audit report should:  Be simple and clear.  Be written in plain English.  Use a structured, systematic approach, for example, IMRAD (introduction, method, results and discussion which would include recommendations and an agreed quality improvement plan).  Present descriptive statistics graphically where possible  Make sense and follow a logical progression.  Be easy to understand – the report should be written in such a way that it could be understood by a colleague from a different discipline. A good report will make even a complex issue understandable to all. Layout of report The audit report should follow a standard audit report template. Examples SAMPLE TEMPLATE FOR CLINICAL AUDIT REPORT  Introduction Explain the reasoning why the audit was undertaken. Outline when the audit undertaken and how many people/items were surveyed. Outline the aims and objectives of the audit.  Method and Sample Briefly explain the method used and how the sample was chosen. This section should include enough detail to allow anyone re-auditing to use the same approach and methodology. It should include: Who was involved; what type of data collection tool or scale was used; any difficulties experienced; timescales and any expectations.  Results There should be no commentary in this section. Anonymity should be heeded i.e. don’t refer to specific people. Where possible use visual aids such as tables or charts. All tables and figures should have a title and be understood without reference to the text. Be consistent with data presentation, e.g. decimal places, percentages, format.  Discussion This section should not contain any new data. It should draw on the results and make careful interpretation of the findings. Compare the results to other audits. Discuss the strengths and weakness of the audit, are there any discrepancies? Discuss the meaning of the findings and possible implications for health care professionals.  Conclusion and recommendations Use this section to summarise. Put forward recommendations for change, for example, better documentation, training requirements, change of practice. Recommendations should be realistic and achievable.
  • 2. 2 Suggest areas for further works and plans for re-audit if appropriate.  Quality improvement plan The quality improvement plan is a fundamental part of the audit, without it the audit is not effective and has just wasted time, money and effort. The audit loop is completed by developing and implementing the quality improvement plan, use bullet points to keep it short and to the point. The quality improvement plan should identify the person/s responsible for each action. Plan a date for re-audit.  Acknowledgements All those who helped should be mentioned  References Should be numbered or in alphabetical order.  Appendices It may be appropriate to include a copy of the data collection form Another version of a template for a clinical audit report is provided on the next page.
  • 3. 3 SAMPLE TEMPLATE FOR CLINICAL AUDIT REPORT (VERSION 2) Title of Audit: For office use: audit number Date of report: Department/Speciality: Re-audit date: Audit lead/author: Job title: Service provider: Job title: Key stakeholders: Names: Department/ Speciality: Background & aim: Say why the audit was done. Perhaps a problem had been identified? Statement of what the project is trying to achieve: Standard: Methodology: State  Chosen population  How sample selected  Retrospective or prospective  Sample size  Describe tool used Results: (State the results. Start with total number (n=). Data may be presented visually (graphs, tables)
  • 4. 4 Conclusion: (List key points that flow from results) Recommendation: (bullet point action plan-with review date and initials of person in charge of implementation) A report must be written up for each Clinical Audit done. This is the official record of what has been done, which can be returned to in future years. Title This should be the same as the title on the proforma. Background & aim(s) of the audit (Introduction) This is essentially narration, clarifying why the audit was done. For example, was the project prompted by an identified local problem or concern? The background should explain the rationale for doing the audit. Summarise the evidence base for the audit topic, giving any references at the end. If a team was convened to undertake this audit, say how this was organised and who was involved. This will explain what the project is trying to achieve and should have been identified before the audit commenced. Standards Clinical audit must measure against standards, guidelines or benchmarks of some sort, these should be identified and where they come from (the source and strength of evidence). State if the intention was to set standards at the end of the project and if so, which aspects of care those standards pertain to. Methodology State the chosen population for this study (for example, "patients referred to the one-stop breast clinic for suspected cancer") and then to say how the sample was selected the sample for the audit, specifying whether a retrospective or prospective approach was used (for example, for a prospective audit, "the first 100 patients referred to the clinic starting from 1/10/04", or for a retrospective audit, "all patients seen at the outpatient clinic during July "). Describe how these patients were identified, the sample size, the time period, and clarify how this was calculated or agreed upon. The data collection method should also be stated, for example, "Data was collected from patients' case notes using a data collection sheet or a query was run in ICT. List who was responsible for data collection, when this was done, and mention briefly the method of data input (if appropriate) and analysis. Results The number of subjects (for example, patients) included in the audit is the initial 'n' number. If data is incomplete, explain why, for example, it might not be possible to find every set of patient notes. How data is analysed depends upon the question/s to be answered. Ensure to include the number and percentage of cases meeting each criteria of the standard, making it clear what number is been taken a percentage of as the 'n' number may change at different points of the report, for example, 45/50 (90%) for criterion A and 81/90 (90%) for criterion B. Conclusions List the key points that flow from the audit results - use bullet points and avoid long paragraphs. Ensure conclusions are supported by the data, or if the data points to no firm conclusions, say so - don't make claims that are not supported by the evidence. Make objective, factual statements, not subjective ones, i.e. don't say "it is obvious that... “or "clearly, what is happening is ... " Recommendations & Quality Improvement Plan Recommendations for change should be made. Make sure these are realistic and achievable. A quality improvement plan (action plan) should be agreed saying what changes will be implemented, who will be responsible for carrying them out and when this will be done. If appropriate (i.e. changes are to be made), set a date for a re-audit to complete the audit cycle.