# Clinical Audit Report: [Audit topic]

> Clinical audit report structured by the audit cycle: choose a topic,
> set standards and criteria, measure current practice, compare with the
> standards, implement change and re-audit. Based on common clinical
> governance practice for quality improvement. This is a reporting format,
> not clinical advice. Use aggregate, de-identified data only, and follow
> local privacy law (for example HIPAA or GDPR) and your institution's
> audit registration and information governance policy.

<!--
Guidance: How to use this template
- Register the audit with your clinical governance or audit department
  before collecting data, and agree the standards before you look at
  practice.
- Each criterion must be measurable as yes or no for one case, with
  explicit exceptions, so that compliance can be calculated.
- Report results as aggregate numbers. Never include patient identifiers
  or identifiable staff names in the report.
- An audit without an action plan and a re-audit date is incomplete: the
  value is in closing the loop.
-->

| Field | Value |
|---|---|
| Audit ID | [AUD-2026-017] |
| Audit title | [Topic] |
| Department / service | [Department] |
| Audit lead | [Name, role] |
| Team members | [Names, roles] |
| Registered with | [Clinical audit department, registration number] |
| Cycle | [First audit / Re-audit of AUD-ID] |
| Data collection period | YYYY-MM-DD to YYYY-MM-DD |
| Report date | YYYY-MM-DD |
| Status | [Draft / Presented / Actions in progress / Closed] |

The audit follows the cycle below; this report covers one turn of it.

```mermaid
flowchart LR
    A[Select topic] --> B[Set standards and criteria]
    B --> C[Measure current practice]
    C --> D[Compare with standards]
    D --> E[Implement change]
    E --> F[Re-audit]
    F --> C
```

## 1. Topic and rationale

<!-- Guidance: Explain why this topic was chosen: high risk, high volume, high cost, an incident, a new guideline or a patient concern. -->

[Describe the topic and why it matters.] *Example:* Venous
thromboembolism (VTE) is a leading cause of preventable hospital death.
A recent incident review found that a risk assessment had not been
completed on admission, and the national guideline was updated in
[year].

**Aim:** [One sentence, for example to determine whether adult medical
inpatients receive a documented VTE risk assessment within 14 hours of
admission.]

**Objectives:**

1. [Measure compliance with criterion C1]
2. [Measure compliance with criterion C2]
3. [Identify reasons for non-compliance and agree actions]

## 2. Standards and criteria

<!-- Guidance: Base standards on the best available evidence (national guidelines, professional body standards). Each criterion has a target and defined exceptions. -->

| ID | Criterion | Target | Exceptions | Source of standard |
|---|---|---|---|---|
| C1 | *Example:* Adult inpatients have a documented VTE risk assessment within 14 hours of admission | 95% | Admitted for under 24 hours; end-of-life care | [Guideline reference] |
| C2 | [Patients assessed as at risk receive prophylaxis or a documented reason why not] | [95%] | [Contraindication documented] | [Reference] |
| C3 | [Risk is reassessed within 24 hours of admission] | [90%] | [Exceptions] | [Reference] |

## 3. Method

<!-- Guidance: Describe the sample, how it was selected, the data source, who collected the data and how quality was assured. Enough detail for the re-audit to repeat it exactly. -->

The method is recorded so the re-audit can repeat it exactly.

| Item | Detail |
|---|---|
| Audit type | [Retrospective / prospective] |
| Population | [All adult admissions to wards X and Y] |
| Sample size and selection | *Example:* 60 consecutive admissions from YYYY-MM-DD |
| Inclusion criteria | [Criteria] |
| Exclusion criteria | [Criteria, matching the exceptions above] |
| Data source | [Electronic record, drug chart] |
| Data collection tool | [Proforma version, appendix A] |
| Data collected by | [Roles; training given] |
| Data quality check | [10% of cases re-abstracted by second auditor] |
| Information governance | [Approval reference; data stored de-identified on approved drive] |

## 4. Results compared with standards

<!-- Guidance: For each criterion, give the number of cases that met it, the number applicable after exceptions and the compliance percentage, with the target beside it. -->

Compliance for each criterion is calculated as:

$$
\text{Compliance (\%)} = \frac{\text{cases meeting the criterion}}{\text{cases eligible for the criterion}} \times 100
$$

where eligible cases exclude documented exceptions. *Example:* For C1,
$47 / 56 \times 100 = 83.9\%$ against a target of 95%.

| ID | Criterion (short) | Eligible (n) | Met (n) | Compliance | Target | Met target? |
|---|---|---|---|---|---|---|
| C1 | VTE assessment within 14 h | [56] | [47] | [83.9%] | 95% | [No] |
| C2 | Prophylaxis or reason documented | [31] | [29] | [93.5%] | 95% | [No] |
| C3 | Reassessment within 24 h | [56] | [22] | [39.3%] | 90% | [No] |

Excluded cases: [n, with reasons]. For a re-audit, add the previous
cycle's compliance in a separate column to show change.

## 5. Analysis

<!-- Guidance: Explain why the standards were or were not met. Look for patterns by time, ward, staff group or patient group. Avoid blaming individuals; focus on systems. -->

[Interpret the results.] *Example:* Compliance with C1 was lower for
admissions between 22:00 and 08:00 (68%) than during the day (92%).
Reassessment (C3) was rarely documented because the electronic record has
no prompt after the first assessment.

| Finding | Likely cause | Evidence |
|---|---|---|
| [Lower compliance overnight] | [Fewer staff; assessment deferred to day team] | [Time-of-admission breakdown] |
| [Reassessment rarely documented] | [No system prompt] | [Staff survey, n = 14] |
| [Finding] | [Cause] | [Evidence] |

Limitations: [sample size, retrospective data, documentation versus
practice].

## 6. Conclusions

<!-- Guidance: State plainly which standards were met and which were not. -->

[Summarise compliance against each standard and the main areas for
improvement.]

## 7. Action plan

<!-- Guidance: Each action is specific, owned, dated and linked to a finding. Agree actions with the people who will carry them out, and present the audit to the department. -->

| ID | Action | Linked finding | Owner | Due date | Status |
|---|---|---|---|---|---|
| ACT-01 | *Example:* Add mandatory VTE assessment field to the admission clerking template | C1 overnight gap | [Role] | YYYY-MM-DD | [Not started / in progress / done] |
| ACT-02 | [Add 24-hour reassessment prompt to electronic record] | C3 | [Role] | YYYY-MM-DD | [Status] |
| ACT-03 | [Teaching session at junior doctor induction] | C1, C2 | [Role] | YYYY-MM-DD | [Status] |
| ACT-04 | Present findings at departmental governance meeting | All | [Audit lead] | YYYY-MM-DD | [Status] |

## 8. Re-audit

<!-- Guidance: Set the date now. Allow enough time for actions to take effect, usually 3-12 months. Use the same criteria and method. -->

| Item | Detail |
|---|---|
| Planned re-audit date | YYYY-MM-DD |
| Re-audit lead | [Name, role] |
| Method | Same criteria, sample size and data source as this cycle |
| Success measure | [All criteria at or above target, or a stated improvement] |

## 9. Dissemination and sign-off

<!-- Guidance: Record where the audit was presented and who accepted the action plan. -->

| Presented to | Date | Outcome |
|---|---|---|
| [Department governance meeting] | YYYY-MM-DD | [Action plan agreed] |
| [Clinical audit committee] | YYYY-MM-DD | [Outcome] |

| Role | Name | Signature | Date |
|---|---|---|---|
| Audit lead | [Name] | [Signature] | YYYY-MM-DD |
| Clinical lead / supervisor | [Name] | [Signature] | YYYY-MM-DD |

## Standard and licence note

Based on common clinical governance practice for clinical audit and the
widely used audit cycle (select topic, set standards, measure, compare,
change, re-audit). This template is original text written for this
collection. This is a reporting format, not clinical advice; follow
local privacy law and your institution's clinical audit and information
governance policies. Template licence: MIT.