Consent episodes reviewed
54
Sample data
Overall compliance
77.1%
Local target 90%
Material risks documented
72.9%
Individualised material risks
Capacity considered
79.6%
Mental Capacity Act consideration
Aim
To assess whether consent documentation supports safe, lawful, person-centred decision-making and provides a clear record of the discussion, decision, capacity considerations and agreed plan.
Standard
Local audit standard: at least 90% compliance with each consent documentation criterion, informed by GMC Decision making and consent, NICE NG197 and local consent policy.
Sample
Target sample 100 consent episodes (retrospective review of hybrid records). Pseudonymised only — no direct patient identifiers.
Tool workflow
Step 1
Project setup
Scope, locations, leads, policy references and sources.
Step 2
Team
Supervisors, contributors, MCA, safeguarding and governance leads.
Step 3
Inclusion / exclusion
Who is in scope and the 31 audit criteria.
Step 4
Data collection
Structured form for each consent episode.
Step 5
Dashboard
Compliance, variation, run chart and documentation gaps.
Step 6
Findings
Interpretation, good practice and gaps.
Step 7
Improvement
Actions, PDSA cycles, sustainability and re-audit.
Step 8
Resources
GMC, NICE NG197, MCA and local policy sources.
Step 9
Export centre
Word, PowerPoint, poster, Excel and ARCP outputs.
Add a consent episode
Open the structured data collection form.
Plan improvement
Actions, PDSA cycles and re-audit plan.
Generate outputs
Word, PowerPoint, A0 poster, Excel and ARCP evidence.
Clinical safety note
This tool supports local audit, quality improvement and governance review. It does not replace clinical judgement, local consent policy, professional guidance, the Mental Capacity Act, safeguarding procedures, specialist advice, legal advice, emergency treatment pathways or incident reporting processes. Any concern about invalid consent, capacity, coercion, safeguarding, serious communication failure, wrong procedure, material undisclosed risk, or patient harm must be escalated according to local policy. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers.