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2.5.1. Title page and contents page<br />

The title page should include the name and address of the facility/institution<br />

audited, the names of the members of the audit team (including identification of<br />

the leader), the date of the audit and any identification required by the auditing<br />

facility/institution. A contents page is essential, and this is generated<br />

automatically by the document template.<br />

2.5.2. Executive summary<br />

The summary should describe the reasons for a comprehensive clinical<br />

audit, and comment on the extent to which the facility/institution has met the<br />

criteria for good practice as outlined in these guidelines, along with the vision of<br />

the facility/institution for the future, concluding with a summary of<br />

recommendations to the clinical facility and the external organizations. This<br />

section should not exceed two pages in length.<br />

2.5.3. Recommendations<br />

Recommendations will be prepared for two recipients:<br />

(1) The audited facility/institution. These recommendations should address<br />

minor or major issues potentially resolvable by the facility/institution. They<br />

should be grouped using the sections in this guide to allow the audited<br />

institution to rapidly reference the appropriate sections. A summary of these<br />

recommendations is included in the executive summary as mentioned<br />

above.<br />

(2) External organizations (e.g. government agencies). These<br />

recommendations should address major issues that may require intervention<br />

from outside the facility/institution for resolution, and other<br />

recommendations that should be brought to the attention of the government.<br />

These recommendations are usually included in the executive summary;<br />

however, if they are detailed and lengthy they could form a distinct section.<br />

All recommendations should be reviewed, with those of major importance as<br />

determined by the audit team being highlighted. A short summary of such a<br />

recommendation should appear in the executive summary. Any issues involving<br />

serious safety concerns should be appropriately indicated.<br />

Recommendations that deal with issues within the authority of the auditing<br />

body, for example, the need for additional training of auditors, will not be part of<br />

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