how to write an audit report

8/3/2019 How to Write an Audit Report

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How to write an audit report

What should be in a clinical audit report?

Clinical Audit reports should include:

Front page

Name of the organization and name of division/specialty

Project title

Project lead/s (and name of the person who wrote the report, if

different)

Date of report

Table of contents-recommended if report runs to more than eightpages

Executive summary

It is good practice to begin a report with an executive summary (or

'abstract'). This should be a short paragraph (certainly no more than 10% of the total length of

the report) that encapsulates the main thrust of the report. Identify the issue, state the key

findings, conclusions and what course of action is recommended. This will help people

identify whether they need to read the full report, and will be a useful prcis for busymanagers. You may (instead of or in addition to an executive summary) want to produce a

one A4 page summary of the report for this purpose, especially if the report is very long.

Background

This is essentially narration, clarifying why the audit was done. For

example, was the project prompted by an identified local problem or

concern? The background should explain the rationale for doing the audit,

i.e. why this topic is a priority for quality improvement. Summarize theevidence base for the audit topic; giving full references at the end (see

point 12). If you convened a team to undertake this audit, this is a good

point to say how this was organized and who was involved.

Objectives

These explain what the project is trying to achieve and should have been

identified at the start.


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Standards

Assuming you are measuring against standards, guidelines or benchmarks

of some sort, you need to state what these are (using the

criteria/target/exception format, as detailed in 'How to set audit objectives

and standards') and where they come from (the source and strength of evidence). State if

the intention was to set standards at the end of the project and if so, which aspects of carethose standards pertain to.

Methodology

State your chosen population for this study (e.g. patients referred to the

one-stop breast clinic for suspected cancer) and then go on to say how

you selected the sample for your audit, specifying whether a retrospective

or prospective methodology was used (e.g. for a prospective audit, the

first 100 patients referred to the clinic starting from 1/10/04, or for aretrospective audit, all patients seen at the outpatient clinic during July

2004).

Describe how these patients were identified, e.g. which ICD10 or OPCS4

codes were used.

State the size of your sample and the time period, and clarify how this was

calculated or agreed upon. The data collection method should also be

stated, e.g. Data was collected from patients case notes using an audit

pro-forma (see Appendix A). Also state who was responsible for data

collection and when this was done, and mention briefly the method of

data input (if appropriate) and analysis.

Results

State how many subjects (e.g. patients) were included in the audit. This is

your initial 'n' number. If your data is incomplete, explain why, e.g. you might not be able

to find every set of patient notes. How you analyze your data depends upon the question/s

you want to answer. Ensure you include the number and percentage of cases meeting each

standard, making it clear what number you are taking a percentage of as your 'n' number may

change at different points of the report, e.g. 45/50 (90%). If you use a statistical test (e.g. Chi

Square) to analyze data, state clearly what the test is and whether the results are statistically

significant.

Data may be presented as tables or as a chart. Be selective in your use of charts-only illustrate

the key findings in this way so as not to overburden reader. Use the most appropriate chart for


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each piece of data, e.g. pie charts to show proportions, or bar charts for easy comparison

between different areas or standards. Quote both raw figures & percentages in the chart where

possible. Where you can only have one or the other, pie charts should have the raw figures as

a label by each segment, rather than percentages, as this chart is designed to visually show

proportions percentages).

Charts showing only percentages should be accompanied by a table showing the raw figures-these will be needed when it comes to re-auditing and comparing results. Individual

healthcare staff should not be identifiable in your report audit should not be used as a 'witch

hunt'. If, for example, you are comparing the results of three consultant firms, you could call

them A, B and C. Have the decoder handy though clinicians may wish to identify

themselves! Patients should also not be identified, for confidentiality reasons.

Conclusions

List the key points that flow from your results use bullet points and avoidlong paragraphs. Ensure your conclusions are supported by the data, or if

your data points to no firm conclusions, say so dont make claims that

are not supported by the evidence. Make objective, factual statements,

not subjective ones, i.e. dont say it is obvious that or clearly, what is

happening is

Recommendations

Where appropriate, recommendations for change should be made. Makesure these are realistic and achievable. If you need money to implement

recommendations, have you got access to any suitable funds?

Action Plan

When your report is presented (e.g. at an audit meeting), your

recommendations will either be accepted or revised. Once this has been

done, and action plan should be agreed (preferably at that meeting)

saying what changes will be implemented, who will be responsible forcarrying them out and when this will be done. Include this either in the

body of the report, or if the report is already written, as an addendum to

the full report. If appropriate (i.e. changes are to be made), set a date for

a re-audit to complete the audit cycle.

References


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The full references of the evidence base referred to in your background.

Try to be consistent in the way you reference if you are hoping to get

your project published, some journals are quite particular about how

references are listed. The Vancouverstyle favored by the BMJ and other

journals numbers references I the order in which they appear in the text.

Give the names and initials of all authors followed by the title of the

article, the title of the journal, the year of publication, the volume number

and the first and last page numbers. References to books should give the

names of any editors, place of publication, publisher and year.

Appendices

Include a copy of the pro-forma/questionnaire that you used for data

collection.

Tips for reports

Think about who is going to read your report and gear the content

and style accordingly. With this, also think about what are you trying

to achieve e.g. if you need to persuade people of the need for

action, make sure your report reads persuasively and puts a good

case.

Make it look professional but also like something that people would

want to read! Use colors and fonts sensibly, but be consistent. Arial isan easily readable font.

Your report should have a logical flow to it and all the words should

be understandable. This will all help to make it more readable. Make

the structure explicit by using section headings and paragraphs

(numbered if necessary). Dont forget page numbers!

Every word in your report should count for something. Dont

embellish your report unnecessarily (e.g. With this in mind or Allthings considered). An audit report should be largely descriptive

(statement of facts), although it can sometimes be appropriate to

include opinions and anecdotes.

Even if your readers understand the terms you are using, particularly

abbreviations and acronyms, it is good practice to write these out in

full in the first instance.


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Ask someone else to proof read your report before you distribute it

youll be amazed at the mistakes youve missed however many

times youve checked it yourself! This is also an opportunity for your

proof-reader to say 'I didnt quite understand this bit' or 'this bit didnt flow very

well', which gives you a chance to express yourself more clearly in the version you

send out.

Start writing your report early on in the audit process - everything up to the results

section can be written before you start collecting and analyzing your data. Results etc

can then be added in as you go along, with the report only being finalized after the

action plan is agreed. This makes for less work at the end to finish off the project

before moving on to some other topic!

how to write an audit report

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