Case note audit tool

Date Reviewed:


This audit tool, developed by the team in Newcastle working on the Health Foundation's MAGIC programme, is designed for use to audit case notes for written evidence that the shared decision making process has been implemented.

The tool, developed to check compliance with CQUIN indicators for shared decision making, consists of a series of 7 questions.  The questions check whether there is evidence that options were discussed and understood, that the clinicians sought the patient's views, that the patient's preference was recorded and that a decision was made.

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