Audit

Client & Patient Details

Client Surname

Patient Name

Doctor Details
Doctor Surname

Medical Content

Problem Type Selection
What is the Problem Type?
Which body system is predominately affected?

Consultation Structure

Did the doctor initiate the welcome!

Did the doctor introduce themselves?

Did the doctor shake hands during the welcome?

Did the doctor seek an appropriate medical history?

Did the doctor conduct a physical examination, describing what they were doing?

Did the doctor describe their findings, in a narrative, relevant to the presenting complaint?

Did the doctor describe a medically appropriate diagnostic and therapeutic plan?

Did the doctor seek understanding of the findings and the plan by the use of reflective listening, and good questions?

Consultation Room Delivery

Was the doctor's pace of speech ...

How did you hear the doctor's tone?

Was the doctor's body language...

Blocking words

Did the doctor use any blocking words?
e.g. "See how it goes". "Wait and see". "Probably be okay.." " it could wait".

Which phrases were used?

Did the doctor use the word " NEEDS" rather than "recommend" in discussing the plan?

Plans and Estimates

Did the doctor provide a plan in detail BEFORE providing an estimate?

Did the doctor seek agreement to a medical plan BEFORE providing an estimate?

Did the client raise any objections to the plan BEFORE an estimate was provided?

How well did the doctor respond to any objections?

Did the doctor deliver the estimate and healthcare plan?

Did the client raise any objections to the plan AFTER an estimate was provided?

How well did the doctor respond to any objections?
How well did the nurse respond to any objections?