Audit tool

Patient record audit: informed consent for procedures (JCI ACC.3, MOI.2)

Audit patient records for informed consent for procedures, checking for form presence, procedure details, explanation of risks/benefits/alternatives, signatures, dates, and interpreter documentation.

Fill it in online - free, no account needed. 32 questions.

What it is for

This template provides a structured audit tool for assessing informed consent documentation in patient records.

The full question list

1. Record Identification and Consent Form Presence

  1. Patient Record Number *
  2. Date of Procedure *
  3. A completed consent form for the procedure is present in the patient record. *

2. Procedure Details and Explanation

  1. The consent form clearly names the specific procedure to be performed. *
  2. The consent form or associated documentation records that the risks of the procedure were explained to the patient. *
  3. The consent form or associated documentation records that the benefits of the procedure were explained to the patient. *
  4. The consent form or associated documentation records that alternatives to the procedure were explained to the patient. *
  5. The consent form or associated documentation records that the patient was informed about the procedure's purpose. *
  6. The consent form or associated documentation records that the patient was informed about potential complications. *

3. Signatures and Dates

  1. The consent form is signed by the patient. *
  2. A legal representative is applicable for this patient's consent.
  3. The consent form is signed by the patient's legal representative (if applicable).
  4. The consent form is dated by the patient. *
  5. A legal representative is applicable for this patient's consent.
  6. The consent form is dated by the patient's legal representative (if applicable).
  7. The consent form is signed by the clinician performing the procedure. *
  8. A different clinician explained the procedure to the patient.
  9. The consent form is signed by the clinician explaining the procedure (if different from performing clinician).
  10. The consent form is dated by the clinician performing the procedure. *
  11. A different clinician explained the procedure to the patient.
  12. The consent form is dated by the clinician explaining the procedure (if different from performing clinician).
  13. The date of the patient's signature on the consent form is prior to the documented start time of the procedure. *
  14. The date of the clinician's signature on the consent form is prior to the documented start time of the procedure. *

4. Interpreter Services

  1. If an interpreter was required, their use is documented in the patient record.
  2. If an interpreter was used, their name is recorded in the patient record.
  3. If an interpreter was used, their identifier is recorded in the patient record.

5. Overall Assessment and Follow-up

  1. The informed consent documentation for this procedure is complete. *
  2. The informed consent documentation for this procedure is timely. *
  3. Notes on any deficiencies or areas for improvement for this record.

6. Audit Completion

  1. Completed by (Auditor's Name) *
  2. Date of Audit *
  3. 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

What is the scope of this audit?

This audit focuses specifically on informed consent documentation for procedures within patient records, covering key elements like form presence, content, signatures, and timeliness.

How often should this audit be conducted?

The frequency of this audit depends on your organisation's internal policies and accreditation requirements. Regular audits are recommended to maintain compliance and identify trends.