Audit tool

Clinician file audit: JCI SQE.7 & SQE.5, healthcare (international)

This template provides an in-depth audit of a clinician's or staff member's file, covering licensure, qualifications, competence, training, and performance review, aligned with JCI SQE.7 and SQE.5 standards.

Fill it in online - free, no account needed. 29 questions.

What it is for

This template helps healthcare organisations audit individual clinician or staff member files to ensure compliance with JCI standards.

The full question list

1. Clinician File Details

  1. Name of clinician/staff member being audited *
  2. Role/position of clinician/staff member *
  3. Date of file audit *
  4. Completed by (name) *

2. Licensure and Registration

  1. A current professional license document is present in the file. *
  2. A current professional registration document is present in the file. *
  3. The professional license is currently in date. *
  4. The professional registration is currently in date. *
  5. The license has been verified with the issuing body. *
  6. The registration has been verified with the issuing body. *
  7. Date of last license/registration verification *

3. Qualifications and Competence

  1. All required academic qualifications are documented in the file. *
  2. Academic qualifications have been verified at source. *
  3. Date of last qualification verification *
  4. The services the clinician is permitted to provide are defined in the file. *
  5. Competence for the current role has been assessed. *
  6. The competence assessment for the current role is documented in the file. *
  7. Date of last competence assessment *
  8. The clinician's file includes evidence of initial assessment of competence for their assigned duties. *

4. Training and Performance

  1. All mandatory training records are present in the file. *
  2. All mandatory training records are current. *
  3. Performance review has been conducted within the last 12 months. *
  4. Date of last performance review *
  5. Any identified performance issues have documented follow-up actions.
  6. The clinician's file contains documentation of at least one performance monitoring activity (e.g., peer review, observation) from the last 12 months. *

5. Follow-up and Sign-off

  1. Any additional notes or observations
  2. Name of auditor *
  3. Date of completion *
  4. Auditor's signature *

References

How the score works

The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.

Questions

Who should use this template?

This template is designed for healthcare compliance officers, HR personnel, or auditors responsible for maintaining and reviewing clinician and staff files in organisations adhering to JCI standards.

How often should a clinician file audit be conducted?

The frequency of audits should align with your organisation's internal policies and accreditation requirements, typically annually or biennially, and upon initial hiring.