Writing an audit standard

One standard, one question

A standard is the criterion a record is judged against, and it works best written as a question with a yes or no answer.

Good: Was blood pressure documented within 24 hours of admission?

That is answerable from a record. Anything vaguer, like Was the patient managed appropriately, is not a standard. It is an opinion, and it will produce judgements you cannot reproduce or defend.

Make it findable in a record

The test is whether a competent colleague reading one note could answer it without asking you what you meant. If they would need to ask, Rhazes has the same problem.

Two specific things to pin down:

• A time window. "Within 24 hours of admission" is auditable. "Promptly" is not.
• What counts as done. If a documented refusal counts, say so, or handle it as an exception.

Several standards, one audit

Most audits have several. Each is judged independently, gets its own compliance figure and its own target, so one standard failing does not drag the others down.

Add as many as you need. You can duplicate a standard, which saves retyping when two criteria share the same inclusion criteria and differ only in the question.

The target

Each standard carries a target compliance percentage. Presets of 80, 90, 95 and 100 are one click, and the slider covers 5 to 100 in steps of 5.

The target does not change the audit. Every record is judged the same way regardless of what you set. What it changes is the verdict: the result is reported as meeting or missing the target, so this is where you record the standard your service is actually held to.

Set it to what the guideline or your contract says, not to what you expect to achieve. An audit that quietly moves its own goalposts to produce a pass is not worth running.

Then the scope

The question is only half a standard. The other half decides which records it applies to at all. See Inclusion criteria and exceptions.