Title Page
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Work Base
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Audit Lead Name & Job Title
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Conducted on
Clinical Audit Proposal Form
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Project Title
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Type of Audit
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Background/Rationale (Why is the clinical audit being done?)
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Additional Reasons (Select all that apply)
- Patient centeredness
- High volume activity
- High risk activity
- High cost activity
- Policy/guideline recommendation
- Professional delvelopment
- Service improvement
- Risk management
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Aims/Objectives (How will the clinical audit improve patient care?)
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Have all the potential stakeholders been identified?
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Are these stakeholders aware of this audit?
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Will patients/service users be involved?
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How? What are your inclusion criteria?
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Estimated Sample Size
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What standards will you be auditing against?
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Type of Data Collection
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Specify
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Method of Data Collection
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Specify
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Data Source (Select all that apply)
- Focus Groups
- Interviews
- I.T. Systems Data
- Observation
- Patient Records
- Peer Review
- Questionnaire
- Telephone Survey
- Other
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Specify
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Anticipated Audit Dates
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I confirm that the information provided on this form is accurate to the best of my knowledge. By signing this form I agree to ensure that this project will be completed, the results disseminated and a report and action plan will be given to both the Quality & Governance Team and Division.
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Audit Lead Name & Signature
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Senior Supervisor Name & Signature
