Audit No
Clinical Audit Proposal Form
MTI – Khyber Teaching Hospital Peshawar
Office use only
Audit Title
Name Specialty
Job Title Tel
Audit Lead: Email
Audit Supervisor Signature of
(For junior Doctors) supervisor
Is this a Re-audit? Yes No
If Yes, have previous audit’s actions have been implemented? Yes No
Scope: (How broad is the focus of this audit)
National Regional Local Interface Audit
Multi-professional? Yes No
If Yes –Kindly, list the professions involved:
1. 2. 3. 4.
Rationale for audit: (Why is this project being undertaken?)
Service evaluation Area of high risk Other (please specify):
Audit of new/updated guidelines Area of high cost
Adverse event Area of high volume
In response to complaints issue
Background
Aims & Objectives
Project Teams Details
Role within Project
Name Job Title Specialty (data collection,
Supervisor etc)
1.
2.
3.
4.
5.
Expected impact of the results on other areas: (Participation details)
What other areas other than Who in this area have you discussed and agreed this audit with?
parent area, will this audit impact
on? (e.g. another Name Job Title Date Agreed
profession/specialty/Institute)
1.
2.
3.
4.
Audit Standards: (e.g. local guidelines, NICE or Royal College guidelines, recommendations
from research studies).
Specify:
Reference:
Methodology:
Retrospective Concurrent Prospective
Case notes review Existing databases
Data Collection Patient/staff questionnaire* Other (please specify):
Add further information below:
____________________________________________________________.
(*Use Validated Questionnaire)
Sample selection criteria:________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Audit Sample:
Acceptable Exceptions criteria: ___________________________________
____________________________________________________________
____________________________________________________________
Sample size:
Expected date to start data collection:
Time Scale
Expected date of presentation of results:
Have you involved patients/clients/users and/or
Patient
Involvement
their carers in the planning and design of this Yes No
project?
Planned Method of Presentation Written report Publication
Dissemination
Personal details, including hospital number, name, address, date of birth etc, should not be
recorded on the data collection tool. Give each patient a unique identifier/number. A separate
‘code sheet' can then be kept as a key, linking each unique identifier to the patient’s hospital
number.
Remember to destroy completed audit proformas and code sheets once an audit has been
presented/written-up and an action plan produced. Only anonymised data should be kept.
Project Lead Declaration:
I understand that the data from this audit must be kept anonymous.
I confirm that the information provided on this form is accurate to the best of my knowledge. By
signing this form I agree that once the audit is completed, the results will be disseminated in the first
instance, and a copy of the audit report will be submitted to the Clinical Audit Convenor of this
institution.
Name: Signature: Date:
Clinical Audit Convenor
I approve the project described above and confirm that it has been appropriately reviewed for
methodological quality, resource implication and importance to the Institution.
Signature: Date:
List of Audit Measures Required to Audit Against the Chosen Standards.
[Link] Audit Measures Target % Clinical Exceptions Instruction on Data Collection
