Clinical Audit Questionnaire

What a COPD clinical audit is

A clinical audit is a structured way of checking whether the care delivered to patients with Chronic Obstructive Pulmonary Disease (COPD) matches current evidence-based best practice criteria. You review the patient's record against a defined set of questions and grade how well practice meets each one, so that the findings can be collected, analyzed, and reported. This questionnaire can be adapted to specific audit topics. The same structure works whether you are auditing a whole service or a single topic within COPD care.

Why this audit matters

COPD care depends on consistent assessment, appropriate referral, and clear self-management planning. An audit makes gaps visible. By recording whether each element is documented and acted on, you can see where assessment is incomplete, where referral criteria have not been applied, or where a patient lacks a written plan for managing exacerbations. The checklist is the tool that supports that work. It turns the criteria into a repeatable set of questions so that findings can be compared and reported with confidence.

What the questionnaire covers

The clinical items fall into a few connected areas: - **Symptom and history review.** You check whether symptoms are documented, including unintentional weight loss, exercise or effort intolerance, nocturnal waking or sleep disturbance, peripheral ankle swelling or edema, persistent fatigue or exhaustion, occupational exposure to respiratory hazards, chest pain or tightness, and haemoptysis (blood in sputum). - **Breathlessness grading.** You confirm whether the MRC dyspnoea scale has been used to grade the patient's breathlessness according to the level of exertion required to elicit symptoms. - **Referral to pulmonary rehabilitation.** You check whether patients with an MRC dyspnoea score of 3, 4, or 5 have been referred to a pulmonary rehabilitation program. - **Oxygenation.** You confirm that pulse oximetry has been performed and recorded to evaluate the patient's oxygenation status. - **Smoking history and cessation.** You check that a current and comprehensive smoking history is documented, that it includes the calculation of smoking pack years, and that where the patient has expressed intent to quit, they have been referred to a smoking cessation service. - **Care planning.** You verify that the patient has a personalized COPD care plan that includes a written self-management strategy for managing exacerbations.

How to carry out the audit

1. Set up the audit by recording the date conducted, who prepared it, and the location. 2. For each patient, begin with the formal COPD assessment question and then work through the clinical evaluation items in the order they appear. 3. Use the patient's record as the source of evidence. If an item is not documented, that is itself a finding. 4. Grade each clinical question using the three-point scale: - **Full Compliance** — the item is fully met as described. - **Partial Compliance** — the item is only partly met. - **Minimal Compliance** — the item is largely or entirely unmet. 5. Pay particular attention to the conditional items. For example, referral to a smoking cessation service applies where the patient has expressed intent to quit, and pulmonary rehabilitation referral is checked against an MRC dyspnoea score of 3, 4, or 5. 6. Close the audit by completing the signature and time fields and recording the inspection start and end dates. 7. Analyze and report the findings once collection is complete, using the recorded compliance levels to describe where care aligns with best practice and where it does not.

Getting the most from the findings

The value of the audit comes from using it consistently. Apply the same questions and the same grading scale across patients so that results can be compared, and keep the recorded evidence tied to what is actually in the patient's record. Because the questionnaire can be adapted to specific audit topics, you can narrow it to the areas you are reviewing while keeping the structure intact. That makes it easier to repeat the audit later and to report on whether practice has changed.

Frequently Asked Questions

The checklist is built around four areas: symptoms and history (weight loss, exercise intolerance, nocturnal waking, ankle swelling, fatigue, occupational exposure, chest pain, haemoptysis); breathlessness grading with the MRC dyspnoea scale; assessment and referral steps (pulse oximetry, smoking history and pack years, smoking cessation referral, pulmonary rehabilitation referral for MRC scores of 3, 4, or 5); and care planning, including a personalized COPD care plan with a written self-management strategy for exacerbations.

The checklist uses a three-point scale for each clinical question: Full Compliance, Partial Compliance, and Minimal Compliance. You record the level that best reflects the documented evidence in the patient's record.

It is designed to evaluate the quality of care delivered to patients with Chronic Obstructive Pulmonary Disease (COPD). The questionnaire can also be adapted to other audit topics and aligned with current evidence-based best practice criteria.

It contains 24 items in total, including administrative fields such as conducted on, prepared by, location, signature, and times, alongside the clinical and assessment questions.

The checklist results can be used to collect, analyze, and report clinical findings on completion. Audit teams can use the recorded compliance levels to identify gaps in care and to support reporting against evidence-based best practice.

Written by

Arne Reis

Founder

Process optimizer with 25 years of expertise, focused on operational excellence in quality, maintenance, EHS, and commissioning. Emphasizes innovative solutions and top-quality standards.

View LinkedIn profile