About this audit
Background, aim and standard
Background
High-quality clinical documentation is essential for patient safety, continuity of care, medico-legal protection and effective communication between teams. National reviews repeatedly identify documentation as a contributing factor in avoidable harm.
Aim
To evaluate the quality and completeness of inpatient clinical documentation against national standards, identify gaps, and inform local improvement actions.
Standard
Royal College of Physicians (RCP) Generic Medical Record Keeping Standards and GMC Good Medical Practice (2024).
This tool supports, but does not replace, clinical judgement. Local policy and specialist advice should be followed.
How to use
Suggested workflow
- 1Review the standard and confirm local context in Setup.
- 2Add your team and supervisors.
- 3Collect data using the structured audit form.
- 4Review dashboards to identify compliance gaps.
- 5Generate reports, posters and ARCP evidence from the Export Centre.
Inclusion criteria
- Adult inpatients (≥18 years) admitted under any medical specialty
- Admission documented within the audit window (last 3 months)
- Minimum 24 hours length of stay
Exclusion criteria
- Day case admissions
- Patients still in the Emergency Department at time of audit
- Records flagged as incomplete due to ongoing serious incident review