Episode details
Context used for dashboard filtering, comparison and reporting.
Applicability
Used to interpret "not applicable" responses in the dashboard.
Audit criteria (0/31 answered)
Compliance uses Yes ÷ (Yes + No). Not applicable and unable to determine are excluded.
Decision and discussion
C1. The specific decision, treatment, investigation, procedure or examination was documented.
C2. The indication or reason for the intervention was documented.
C3. The patient's involvement in the decision was documented.
C4. The person's preferences, priorities or concerns were documented where relevant.
C12. Questions, concerns or discussion points were documented where relevant.
Risks, benefits and alternatives
C5. Benefits of the proposed option were documented where relevant.
C6. Material risks were documented in a way that was relevant to the individual patient.
C7. Common or serious risks were documented where relevant.
C8. Individualised risks were documented where relevant.
C9. Reasonable alternative options were documented where relevant.
C10. The option of no treatment, no procedure or deferral was documented where relevant.
C11. Likely consequences of accepting, declining or delaying the intervention were documented where relevant.
Communication and capacity
C13. Written or patient information was provided or signposted where relevant.
C14. Interpreter use, accessible information or communication support was documented where required.
C15. Capacity was considered.
C16. Mental capacity assessment was documented where required.
C22. Legal proxy, LPA, deputy, parental responsibility or other legal authority was considered where relevant.
C23. Safeguarding, coercion, undue influence or pressure was considered where relevant.
Consent form and authorisation
C17. Consent form was completed where required by local policy.
C18. Correct consent form was used where a form was required.
C19. Consent form was signed, authorised or completed according to local policy.
C20. Consent was reviewed or confirmed on the day of procedure where required by local policy.
C24. Chaperone offer or presence was documented where relevant to examination or procedure.
C25. Sedation, anaesthesia, transfusion, contrast, photography, recording or tissue-use consent was documented where relevant.
Decision, plan and escalation
C21. Refusal, declined treatment or withdrawal of consent was documented where applicable.
C26. Agreed decision and action plan were documented.
C27. Review, follow-up or safety-netting plan was documented where relevant.
C28. Consent information was communicated at handover, transfer or discharge where relevant.
C29. Reason for delayed, missing or incomplete consent documentation was recorded where applicable.
C30. Documentation was clear enough for another clinician to understand the consent discussion, decision and agreed actions.
C31. Any consent-related safety, capacity, safeguarding or governance concern was escalated or actioned where identified.
Context and improvement notes
Safety concern
Ensure any immediate concern about invalid consent, lack of capacity, coercion, safeguarding, wrong procedure, patient refusal, withdrawal of consent, serious communication failure, material risk omission or patient harm is escalated through local clinical, governance, safeguarding, Mental Capacity Act or legal advice pathways. Do not rely on this audit tool for urgent escalation or legal decision-making.
Validation
3 item(s) need attention.
- An anonymous episode reference is required.
- A ward / location is required.
- 31 of 31 criteria still need a response.
Mode
Demo mode — nothing is saved