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Consent episodes reviewed
54
54 in project
Overall compliance
77.1%
Target 90%
Specific decision documented
97.9%
Criterion 1
Patient involvement documented
89.6%
Criterion 3
Material risks documented
72.9%
Criterion 6
Alternatives documented
60.4%
Criterion 9
Capacity considered
79.6%
Criterion 15
Consent form completed
93.5%
Criterion 17 (where required)
Agreed plan documented
89.8%
Criterion 26
Documentation clear to another clinician
84.6%
Criterion 30
Safety concerns
2
Escalated locally
Unable to determine responses
47
Missing data indicator
Compliance by ward / location
Overall compliance across all criteria.
Run chart — compliance over time
Weekly overall compliance with median and local target.
Risk, benefit and alternatives documentation
Capacity and consent form documentation
Documentation gaps (Pareto)
Criteria with the most non-compliant episodes.
C8. Individualised risks were documented where relevant.23 · 12.6% cum.
C11. Likely consequences of accepting, declining or delaying the intervention were documented where relevant.23 · 25.3% cum.
C24. Chaperone offer or presence was documented where relevant to examination or procedure.20 · 36.3% cum.
C4. The person's preferences, priorities or concerns were documented where relevant.19 · 46.7% cum.
C9. Reasonable alternative options were documented where relevant.19 · 57.1% cum.
C28. Consent information was communicated at handover, transfer or discharge where relevant.17 · 66.5% cum.
C29. Reason for delayed, missing or incomplete consent documentation was recorded where applicable.17 · 75.8% cum.
C10. The option of no treatment, no procedure or deferral was documented where relevant.16 · 84.6% cum.
C22. Legal proxy, LPA, deputy, parental responsibility or other legal authority was considered where relevant.14 · 92.3% cum.
C23. Safeguarding, coercion, undue influence or pressure was considered where relevant.14 · 100% cum.
Reasons recorded for documentation gaps
Risks not documented6
Workload / time pressure5
Documentation unclear4
Consent form missing4
Interpreter / communication support not documented4
Capacity not considered2
Criterion-level compliance
Yes ÷ (Yes + No). Not applicable and unable to determine are excluded from the denominator.
Decision and discussion
| # | Criterion | Yes | No | N/A | Unable | Compliance | Status |
|---|---|---|---|---|---|---|---|
| 1 | The specific decision, treatment, investigation, procedure or examination was documented. | 47 | 1 | 4 | 2 | 97.9% | Met |
| 2 | The indication or reason for the intervention was documented. | 49 | 2 | 3 | 0 | 96.1% | Met |
| 3 | The patient's involvement in the decision was documented. | 43 | 5 | 4 | 2 | 89.6% | Below |
| 4 | The person's preferences, priorities or concerns were documented where relevant. | 28 | 19 | 5 | 2 | 59.6% | Below |
| 12 | Questions, concerns or discussion points were documented where relevant. | 38 | 11 | 4 | 1 | 77.6% | Below |
Risks, benefits and alternatives
| # | Criterion | Yes | No | N/A | Unable | Compliance | Status |
|---|---|---|---|---|---|---|---|
| 5 | Benefits of the proposed option were documented where relevant. | 43 | 7 | 2 | 2 | 86% | Below |
| 6 | Material risks were documented in a way that was relevant to the individual patient. | 35 | 13 | 3 | 3 | 72.9% | Below |
| 7 | Common or serious risks were documented where relevant. | 40 | 9 | 3 | 2 | 81.6% | Below |
| 8 | Individualised risks were documented where relevant. | 26 | 23 | 3 | 2 | 53.1% | Below |
| 9 | Reasonable alternative options were documented where relevant. | 29 | 19 | 5 | 1 | 60.4% | Below |
| 10 | The option of no treatment, no procedure or deferral was documented where relevant. | 32 | 16 | 4 | 2 | 66.7% | Below |
| 11 | Likely consequences of accepting, declining or delaying the intervention were documented where relevant. | 24 | 23 | 4 | 3 | 51.1% | Below |
Communication and capacity
| # | Criterion | Yes | No | N/A | Unable | Compliance | Status |
|---|---|---|---|---|---|---|---|
| 13 | Written or patient information was provided or signposted where relevant. | 32 | 12 | 10 | 0 | 72.7% | Below |
| 14 | Interpreter use, accessible information or communication support was documented where required. | 37 | 7 | 7 | 3 | 84.1% | Below |
| 15 | Capacity was considered. | 39 | 10 | 2 | 3 | 79.6% | Below |
| 16 | Mental capacity assessment was documented where required. | 35 | 11 | 5 | 3 | 76.1% | Below |
| 22 | Legal proxy, LPA, deputy, parental responsibility or other legal authority was considered where relevant. | 35 | 14 | 4 | 1 | 71.4% | Below |
| 23 | Safeguarding, coercion, undue influence or pressure was considered where relevant. | 37 | 14 | 3 | 0 | 72.5% | Below |
Consent form and authorisation
| # | Criterion | Yes | No | N/A | Unable | Compliance | Status |
|---|---|---|---|---|---|---|---|
| 17 | Consent form was completed where required by local policy. | 43 | 3 | 7 | 1 | 93.5% | Met |
| 18 | Correct consent form was used where a form was required. | 41 | 3 | 9 | 1 | 93.2% | Met |
| 19 | Consent form was signed, authorised or completed according to local policy. | 40 | 7 | 5 | 2 | 85.1% | Below |
| 20 | Consent was reviewed or confirmed on the day of procedure where required by local policy. | 29 | 13 | 8 | 4 | 69% | Below |
| 24 | Chaperone offer or presence was documented where relevant to examination or procedure. | 23 | 20 | 10 | 1 | 53.5% | Below |
| 25 | Sedation, anaesthesia, transfusion, contrast, photography, recording or tissue-use consent was documented where relevant. | 41 | 8 | 5 | 0 | 83.7% | Below |
Decision, plan and escalation
| # | Criterion | Yes | No | N/A | Unable | Compliance | Status |
|---|---|---|---|---|---|---|---|
| 21 | Refusal, declined treatment or withdrawal of consent was documented where applicable. | 46 | 5 | 3 | 0 | 90.2% | Met |
| 26 | Agreed decision and action plan were documented. | 44 | 5 | 4 | 1 | 89.8% | Below |
| 27 | Review, follow-up or safety-netting plan was documented where relevant. | 38 | 14 | 1 | 1 | 73.1% | Below |
| 28 | Consent information was communicated at handover, transfer or discharge where relevant. | 31 | 17 | 5 | 1 | 64.6% | Below |
| 29 | Reason for delayed, missing or incomplete consent documentation was recorded where applicable. | 32 | 17 | 3 | 2 | 65.3% | Below |
| 30 | Documentation was clear enough for another clinician to understand the consent discussion, decision and agreed actions. | 44 | 8 | 1 | 1 | 84.6% | Below |
| 31 | Any consent-related safety, capacity, safeguarding or governance concern was escalated or actioned where identified. | 44 | 4 | 6 | 0 | 91.7% | Met |
Interpretation
Observed findings from the current filter.
- Overall consent documentation compliance is 77.1% across 54 consent episodes reviewed, with 6 of 31 criteria meeting the local target and 25 below target.
- The weakest criterion is criterion 11 (51.1% against a 90% target): Likely consequences of accepting, declining or delaying the intervention were documented where relevant.
- Compliance varies by location, from 80% (Acute Medical Unit) to 73.4% (Endoscopy Unit); local workflow and template differences may explain part of this variation.
- The most frequently recorded reason for delayed, incomplete or absent consent documentation is "Risks not documented" (6 episodes).
- 2 consent-related safety, capacity, safeguarding or governance concerns were identified and should be reviewed through local escalation routes.
- 47 criterion responses were recorded as "Unable to determine"; where this is frequent, record availability may be limiting interpretation.
Improvement opportunities
Suggested local improvement actions — editable in the Improvement tab.
- Prompt for likely consequences of accepting, declining or delaying the intervention.
- Prompt clinicians to record risks specific to this patient's comorbidities and circumstances.
- Record chaperone offer and presence as a required field for relevant examinations.
- Add a short 'patient priorities and concerns' field to the consent template.
- Add an 'alternatives discussed' field with an explicit option list.
- Include consent status in the handover, transfer and discharge summary templates.