Top 5 Clinical Audit Checklists

Easily identify deficits in crucial areas of patient care by using a mobile clinical audit app to improve the quality of care

What is a Clinical Audit?

A Clinical Audit, formerly known as a Medical Audit, aims to improve the quality of patient care and clinical outcomes through the peer-led review of practice against evidence-based standards. As a quality improvement process, local and national clinical audits can help healthcare practitioners identify deficits in current practice, administer excellent clinical service, and uphold professional standards.

Multidisciplinary teams in healthcare facilities use a clinical audit checklist to ensure the completion of the clinical audit cycle—preparation and planning, selecting the standards/criteria, measuring performance, implementing changes, and sustaining improvements.

Crucial Areas of Patient Care

Preparation and planning for the clinical audit begin by determining exactly what the multidisciplinary team (clinical audit committee) should be auditing. As a rule of thumb, an area of care where obvious shortcomings exist is the starting point of clinical audits. Clinical improvement managers and audit leads should also look at high-volume, high-risk, and high-cost areas such as the following:

Intensive/Critical Care Unit

High-risk sepsis admissions from the ward, unit-acquired infections in the blood, and out-of-hours discharges to the ward have significantly decreased in different parts of the UK as a result of clinical audits. To prevent avoidable infection during patient care, the clinical audit committee should regularly assess the hand hygiene techniques of healthcare practitioners using a mobile-ready hand hygiene audit checklist. After 3-6 months of implementing changes, a clinical re-audit is necessary to validate the effectiveness and sustain improvements.

Medical Records

Quality healthcare is based on accurate and complete clinical documentation in medical records. US healthcare institutions and their associates who handle protected health information should stay compliant with the Health Insurance Portability and Accountability Act (HIPAA) by conducting security risk assessments. The clinical audit committee should evaluate the administrative, physical, and technical safeguards currently in place, address time-sensitive gaps, and avoid costly fines and legal action with a digitized HIPAA compliance and medical checklist, along with SOAP notes for various applications (e.g., occupational therapy).

Admission and Discharge

Non-clinical transfers, unplanned readmissions, and delayed discharges result in low patient satisfaction. The clinical audit committee should inspect transitions of care, medication safety, and outpatient follow-up procedures to reduce bottlenecks and ease patient flow. Starting discharge planning on the date of admission and writing digital SOAP notes, instead of hiring medical scribes, also shortens wait times and encourages more patient-centered care. Common clinical audit improvements include new documentation methods, better communication systems, and efficient checking mechanisms.

Clinical Audit Example

Conduct clinical audits to provide the best care for the patients in the healthcare facility. This practice will ease process review, recordkeeping, and that necessary corrective action will be followed through. View this sample clinical audit PDF and here’s an example of a clinical audit report:

Jona Tarlengco
Article by
Jona Tarlengco
Jona Tarlengco is a content writer and researcher for SafetyCulture since 2018. She usually writes about safety and quality topics, contributing to the creation of well-researched articles. Her 5-year experience in one of the world’s leading business news organisations helps enrich the quality of the information in her work.

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2. Clinical Audit Cycle Checklist
A clinical audit cycle checklist aims to help clinical improvement managers and audit leads to ensure the completion of the 5-stage clinical audit cycle—preparation and planning, selecting the standards/criteria, measuring performance, implementing changes, and sustaining improvements. Access this clinical audit cycle checklist anywhere, any time, and on any iOS, Android, and Windows mobile device to easily check if any step of the 5-stage clinical audit cycle was overlooked and assign actions to clinical audit committee members to resolve them.
3. Medical Audit Checklist
A medical audit checklist is used by multidisciplinary teams to perform a medical record review and evaluate the patient record system of healthcare facilities. Use this digital medical audit checklist to easily determine if the current clinical documentation in medical records are compliant, partly compliant or non-compliant to national regulations or industry standards. This medical audit checklist includes criteria such as clinical notes, patient management plan, immunization history, screening results, medication treatment, etc.
4. Clinical Audit Proposal Form
A clinical audit proposal form specifies the background/rationale, aims/objectives, sample inclusion criteria, standard statement, and method of data collection prior to a local or national government-initiated clinical audit. Identify potential stakeholders and patients or service users to be involved and specify anticipated audit dates with the use of this clinical audit proposal form. Before submission, the audit lead and the audit sponsor, usually a senior supervisor, can digitally affix their signatures in this clinical audit proposal form.
5. Clinical Audit Questionnaire
A clinical audit questionnaire is used by data collectors, usually a part of the clinical audit committee, to measure performance during the clinical audit in a healthcare facility. This clinical audit questionnaire for Chronic Obstructive Pulmonary Disease (COPD) patients can be easily customized according to the selected audit topic and relevant best practices criteria. With SafetyCulture analytics, audit leads can instantly collect and analyze data the moment this clinical audit questionnaire is completed.