Clinical audit compares care with explicit criteria to identify where practice meets an agreed standard and where improvement is needed. Quality improvement is the broader work of changing a process and learning whether the change helps. An audit can identify a gap and later check progress, but collecting audit data alone does not close the gap.
A nursing team should be able to explain which standard it is examining, which patients or encounters are included, and what action it will take with the findings.
Choose criteria that answer a clear question
A criterion describes the aspect of care being assessed. Its source may be current professional guidance or an approved local policy. Record the version, intended population, exclusions, and operational definition. Do not silently convert a recommendation that allows clinical exceptions into a rule that every patient must receive the same intervention.
HQIP's clinical-audit reporting guide asks teams to specify standards, sources, sample selection, data collection, findings, and actions. It was developed for the UK clinical-audit context; its reporting structure can inform a local project without creating a US regulatory requirement.
Separate a care gap from a record gap
If the audit uses documentation, describe the finding as documentation unless the method also establishes what care occurred. An absent entry can have several explanations, including care not delivered, incomplete documentation, or information stored outside the fields being reviewed.
Before collecting a large sample, test the criteria on a few records through an approved process. Check whether different reviewers interpret the same case consistently. Resolve ambiguous rules and document changes to the audit method so that later comparisons remain understandable.
Illustrative audit cycle
An illustrative clinic audit examines whether patients who need a planned follow-up leave with an identified next step. The team defines which visits qualify and how a completed plan is documented. Review finds that some records contain an instruction to arrange follow-up but no clear owner.
The team investigates the scheduling workflow, tests a change assigning responsibility, and repeats the measurement using the same definitions. The example does not establish that the change works or prescribe a clinical follow-up interval. It shows how an audit finding can lead to a testable improvement rather than another report of the same problem.
Report results with their limits
State the period, eligible population, sample method, numerator, denominator, and missing records. Present exceptions and exclusions transparently. A convenience sample can reveal useful problems without establishing the prevalence across the entire service.
HQIP recommends documenting evidence of improvement, which may include repeat audit, improvement-cycle results, or annotated time-series data. A favorable second measurement needs interpretation: changes in case mix, definitions, or documentation can affect the result.
Assign action owners and a review date before closing the project. If a recommendation was not implemented, say so. The audit becomes useful when its findings inform care processes and the team returns to check what changed.
For a repeat audit, check how to keep the measure definition consistent.
Related
Selecting Quality Improvement Measures
Sources
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HQIP: Documenting Local Clinical Audit — A Guide to Reporting and Recording (accessed 2026-09-17).
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IHI: Establishing Measures (accessed 2026-09-17).