How to write an audit report What should be in a clinical audit report?

Clinical Audit reports should include: Front page Name of the organization and name of division/specialty Project title Project lead/s (and name of the person who wrote the report, if different) Date of report Table of contents-recommended if report runs to more than eight pages Executive summary It is good practice to begin a report with an executive summary (or 'abstract'). This should be a short paragraph (certainly no more than 10% of the total length of the report) that encapsulates the main thrust of the report. Identify the issue, state the key findings, conclusions and what course of action is recommended. This will help people identify whether they need to read the full report, and will be a useful prcis for busy managers. You may (instead of or in addition to an executive summary) want to produce a one A4 page summary of the report for this purpose, especially if the report is very long. Background 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, i.e. why this topic is a priority for quality improvement. Summarize the evidence base for the audit topic; giving full references at the end (see point 12). If you convened a team to undertake this audit, this is a good point to say how this was organized and who was involved. Objectives These explain what the project is trying to achieve and should have been identified at the start.

Standards Assuming you are measuring against standards, guidelines or benchmarks of some sort, you need to state what these are (using the criteria/target/exception format, as detailed in 'How to set audit objectives and standards') 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 your chosen population for this study (e.g. patients referred to the one-stop breast clinic for suspected cancer) and then go on to say how you selected the sample for your audit, specifying whether a retrospective or prospective methodology was used (e.g. 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 2004). Describe how these patients were identified, e.g. which ICD10 or OPCS4 codes were used. State the size of your sample and the time period, and clarify how this was calculated or agreed upon. The data collection method should also be stated, e.g. Data was collected from patients case notes using an audit pro-forma (see Appendix A). Also state who was responsible for data collection and when this was done, and mention briefly the method of data input (if appropriate) and analysis. Results State how many subjects (e.g. patients) were included in the audit. This is your initial 'n' number. If your data is incomplete, explain why, e.g. you might not be able to find every set of patient notes. How you analyze your data depends upon the question/s you want to answer. Ensure you include the number and percentage of cases meeting each standard, making it clear what number you are taking a percentage of as your 'n' number may change at different points of the report, e.g. 45/50 (90%). If you use a statistical test (e.g. Chi Square) to analyze data, state clearly what the test is and whether the results are statistically significant. Data may be presented as tables or as a chart. Be selective in your use of charts-only illustrate the key findings in this way so as not to overburden reader. Use the most appropriate chart for

each piece of data, e.g. pie charts to show proportions, or bar charts for easy comparison between different areas or standards. Quote both raw figures & percentages in the chart where possible. Where you can only have one or the other, pie charts should have the raw figures as a label by each segment, rather than percentages, as this chart is designed to visually show proportions percentages). Charts showing only percentages should be accompanied by a table showing the raw figuresthese will be needed when it comes to re-auditing and comparing results. Individual healthcare staff should not be identifiable in your report audit should not be used as a 'witch hunt'. If, for example, you are comparing the results of three consultant firms, you could call them A, B and C. Have the decoder handy though clinicians may wish to identify themselves! Patients should also not be identified, for confidentiality reasons. Conclusions List the key points that flow from your results use bullet points and avoid long paragraphs. Ensure your conclusions are supported by the data, or if your data points to no firm conclusions, say so dont make claims that are not supported by the evidence. Make objective, factual statements, not subjective ones, i.e. dont say it is obvious that or clearly, what is happening is Recommendations Where appropriate, recommendations for change should be made. Make sure these are realistic and achievable. If you need money to implement recommendations, have you got access to any suitable funds? Action Plan When your report is presented (e.g. at an audit meeting), your recommendations will either be accepted or revised. Once this has been done, and action plan should be agreed (preferably at that meeting) saying what changes will be implemented, who will be responsible for carrying them out and when this will be done. Include this either in the body of the report, or if the report is already written, as an addendum to the full report. If appropriate (i.e. changes are to be made), set a date for a re-audit to complete the audit cycle. References

The full references of the evidence base referred to in your background. Try to be consistent in the way you reference if you are hoping to get your project published, some journals are quite particular about how references are listed. The Vancouver style favored by the BMJ and other journals numbers references I the order in which they appear in the text. Give the names and initials of all authors followed by the title of the article, the title of the journal, the year of publication, the volume number and the first and last page numbers. References to books should give the names of any editors, place of publication, publisher and year. Appendices Include a copy of the pro-forma/questionnaire that you used for data collection. Tips for reports Think about who is going to read your report and gear the content and style accordingly. With this, also think about what are you trying to achieve e.g. if you need to persuade people of the need for action, make sure your report reads persuasively and puts a good case.

Make it look professional but also like something that people would want to read! Use colors and fonts sensibly, but be consistent. Arial is an easily readable font. Your report should have a logical flow to it and all the words should be understandable. This will all help to make it more readable. Make the structure explicit by using section headings and paragraphs (numbered if necessary). Dont forget page numbers! Every word in your report should count for something. Dont embellish your report unnecessarily (e.g. With this in mind or All things considered). An audit report should be largely descriptive (statement of facts), although it can sometimes be appropriate to include opinions and anecdotes.

Even if your readers understand the terms you are using, particularly abbreviations and acronyms, it is good practice to write these out in full in the first instance.

Ask someone else to proof read your report before you distribute it youll be amazed at the mistakes youve missed however many times youve checked it yourself! This is also an opportunity for your proof-reader to say 'I didnt quite understand this bit' or 'this bit didnt flow very well', which gives you a chance to express yourself more clearly in the version you send out. Start writing your report early on in the audit process - everything up to the results section can be written before you start collecting and analyzing your data. Results etc can then be added in as you go along, with the report only being finalized after the action plan is agreed. This makes for less work at the end to finish off the project before moving on to some other topic!