Documentation Standards Audit

The Documentation Standards Audit measures whether clinical entries meet recognised standards including author identification, date/time, clinical context, plan and review.

• Trainees of all grades
• Consultants and SAS doctors
• Nursing and AHP teams
• Governance and Audit leads

• Measure compliance against documentation standards
• Identify common gaps in entry quality
• Support training, induction and supervision
• Generate ARCP-ready evidence

• Anonymised case identifier
• Entry type and author grade
• Presence of date, time, author
• Documentation of assessment, plan and review

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Lazomis QI GuidesWhy Clinical Governance Needs Better Data: From Compliance to ImprovementThis article explains why robust data is crucial for effective clinical governance, shifting its focus from mere compliance to active, continuous improvement in patient care and service delivery.
• Clinical GovernanceHow to Write an Effective Action Plan for Clinical GovernanceThis guide provides practical steps for creating robust action plans within NHS clinical governance frameworks, ensuring risks are mitigated and quality improved systematically.
• Clinical GovernancePresenting Audit Findings at Clinical Governance MeetingsEffectively presenting clinical audit findings at governance meetings is crucial for translating data into tangible improvements. This guide outlines how to structure your presentation for maximum impact.
• Digital Health and AIAI-Assisted Clinical Audit: Navigating Opportunities and GovernanceThis guide explores the emerging role of Artificial Intelligence (AI) in clinical audit, offering NHS teams a practical perspective on opportunities for enhanced efficiency and deeper insights, alongside crucial considerations for governance and safe implementation.