Maintaining high standards of documentation is vital for delivering quality, safe, and person-centred palliative care. Our Clinical Case Notes Audit service provides a robust, objective way to assess your record keeping and clinical decision making, supporting both governance and continuous improvement within your organisation.
Why you might need us
In the fast-paced world of healthcare, it can be challenging to ensure that documentation consistently reflects the high-quality care being delivered. National Information Standards, CQC assessments, and good record keeping guidance all emphasise the importance of evidencing safe, effective, and compassionate care.However, for specialist palliative care teams, generic audit tools rarely capture the nuances of complex clinical decision making.
That is where we come in. Our Clinical Case Notes Audit provides a specialist, consultant led review tailored to your setting, helping you demonstrate quality, identify strengths, and highlight areas for improvement.
What we offer
Our audit process is led by senior SCUK consultants, all GMC registered and with substantive NHS experience in palliative medicine. Acting as a “critical friend,” they independently assess a sample of your patient case notes to evaluate:
Evidence of good record keeping
Quality of clinical advice given
Using our bespoke audit template and thematic analysis, we generate a comprehensive report incorporating both qualitative insights and quantitative findings. The process typically includes:
Formal proposal and project agreement
Data Sharing Agreement and IT setup – secure consultant only access via client funded laptops
Audit of 30 patient records – selected at random from referrals within the past 12 months
Six to eight week review and reporting period
Verbal feedback session – with written recommendations and actionable next steps
This structured, transparent approach helps ensure your team gains meaningful insights that can directly inform governance, policy updates, and everyday clinical practice.
What you will get from us
Partnering with us for your Clinical case notes audit provides:
A quality assured review process aligned with national standards
Independent consultant level feedback from palliative medicine specialists
Clear evidence of good practice and improvement opportunities
Benchmarking data to support governance and CQC compliance
Objective insights to guide staff training and procedural development
A detailed report combining statistical and thematic findings
Verbal feedback and recommendations for sustainable improvement
Re-Audit Option
For organisations committed to ongoing quality assurance, our re-audit service revisits the original scope to assess progress over the past six to twelve months. It offers objective measurement of whether recommended improvements have been embedded into clinical practice and documentation standards.
Make an enquiry
Your partner in clinical case notes auditOur partner organisations
We are proud to have developed partnerships with some fantastic organisations to deliver clinical case notes audits.
Having access to such experienced and eminent palliative care consultants brings real benefits for our staff and patients, and gives our management team peace of mind. I would highly recommend Supportive Care UK to other hospices.
