Project details
Sample values shown — sign in to configure a live project.
Aim and standard
Leads and responsibilities
Names and roles included in generated outputs. Do not enter patient information.
Local policy references
Used in the methodology and governance sections of every output.
Wards / locations
Organisation-specific locations offered in the data collection form. Deactivate rather than delete locations already used in submissions.
Acute Medical Unit
Endoscopy Unit
Interventional Radiology
Surgical Ward 4
Outpatient Clinic B
Emergency Department
Departments
Acute Medicine
Gastroenterology
Radiology
General Surgery
Emergency Medicine
Specialties
General internal medicine
Gastroenterology
Interventional radiology
Upper GI surgery
Emergency medicine
Services / teams
Same-day emergency care
Endoscopy service
Day-case procedure service
Pre-assessment service
Inpatient ward care
Guidance and local sources
Sources appear in Resources and, where selected, in generated outputs. Provide a working link for each source — do not add unlinked or dead references.
System metadata
Assigned automatically. Visible to users but not editable.
Project type
Clinical Audit
Quality Improvement Project
CQC domains
Safe
Effective
Caring
Responsive
Well-led
Patient Flow project
No
Patient Flow categories are not applicable to this tool and are kept separate from departments.
Clinical themes
Documentation
Shared Decision Making
Consent
Mental Capacity
Patient Safety
Tool: Consent Documentation Audit · v1.0.0
Local audit standards
Default local targets — adjust the overall target above.
Consent episodes documenting the specific decision or intervention90%
Consent episodes documenting patient involvement in the decision90%
Consent episodes documenting benefits, material risks and reasonable alternatives where relevant90%
Consent episodes documenting capacity consideration90%
Consent episodes with a completed consent form where required by local policy90%
Consent episodes documenting interpreter or communication support where required90%
Consent episodes documenting refusal, withdrawal or change of decision where applicable90%
Consent episodes documenting the agreed decision and action plan90%
Consent episodes with documentation clear enough for another clinician to follow90%
Consent-related safety, capacity, safeguarding or governance concerns escalated or actioned where identified90%
Inclusion criteria
- Adults aged 16 years or older unless locally adapted.
- Patients undergoing or being offered an investigation, treatment, procedure, examination or care decision where consent should be documented.
- Patients where written, verbal or non-verbal consent was documented or should reasonably have been documented under local policy.
- Patients where shared decision-making documentation was clinically relevant.
- Patients where risks, benefits, alternatives or the option of no treatment should reasonably have been discussed and documented.
- Patients where capacity, communication support, interpreter use, family involvement or legal authority was relevant to consent documentation.
- Patients managed in selected wards, units, departments or pathways.
- Electronic, paper or hybrid records depending on local setup.
Exclusion criteria
- Patients under 16 years old unless locally adapted.
- Paediatric consent pathways unless locally adapted.
- Maternity-specific consent pathways unless locally adapted.
- Emergency life-saving treatment where consent documentation was not possible at the time and local emergency treatment standards apply.
- Patients lacking capacity where the relevant process is better audited under a capacity documentation audit unless locally included.
- Cases where consent documentation is held only in a restricted system that the audit team is not authorised to access.
- Duplicate records or duplicate consent episodes.
- Records outside the selected audit period.
- Records unavailable for review.
- Cases where local governance approval is required but has not been obtained.
- Direct patient identifiers entered into the tool.