Clinical Audit Report Template

Clinical audit report by the audit cycle: standards and targets, method, compliance % vs standards, action plan, re-audit

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Як використовувати: Use for a registered clinical audit or re-audit. Agree measurable criteria with targets and exceptions before collecting data. Main pitfall: no owned, dated action plan or re-audit date, so the loop never closes.

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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.

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.

1. Topic and rationale

[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:

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

2. Standards and criteria

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

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

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

[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

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

7. Action plan

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

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

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.

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