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Templates

Policy and clinical note templates, as wai keeps them

Policies, consent forms, SOPs and inspection checklists for 31 health regulators, from CQC policy templates to JCI and Joint Commission checklists, each mapped to the regulator's own standards. Clinical note templates for 8 specialties sit beside them, each shown filled in by the wai scribe, and every document is on its page in full with the editable version by email.

159 documents. Updated .

POL-SG-01PolicyTemplatev1.0, CQC edition [Clinic name]Controlled document Safeguarding policy

1Purpose

  1. 1.1This policy sets out how [Clinic name] protects children and adults at risk from abuse and neglect, and how every member of staff raises a concern.
  2. 1.2It supports the safeguarding standards CQC applies, set out in the mapping at the end of this document.

2Scope

  1. 2.1This policy applies to every member of staff, clinician, contractor and volunteer at [Clinic name], whether or not they see patients.
 Read the CQC safeguarding policy in full

Clinical notes, by specialty

  1. Private GPSOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  2. DermatologySOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  3. AestheticsSOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  4. FertilitySOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  5. PhysiotherapySOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  6. Mental healthSOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  7. DentalSOAP noteInitial consultation noteFollow-up noteProcedure note4 notes
  8. Longevity medicineSOAP noteInitial consultation noteFollow-up noteProcedure note4 notes

CQC, England

  1. PolicyCQC clinical records policyCQC
  2. Consent formCQC consent to treatment formCQC
  3. SOPCQC incident reporting and learning procedureCQC
  4. ChecklistCQC inspection checklistCQC
  5. PolicyCQC safeguarding policyCQC

DHA, Dubai, United Arab Emirates

  1. PolicyDHA clinical records policyDHA
  2. Consent formDHA consent to treatment formDHA
  3. SOPDHA quarterly self inspection procedureDHA
  4. ChecklistDHA inspection checklistDHA

HCSA, Singapore

  1. PolicyHCSA clinical records policyHCSA
  2. Consent formHCSA consent to treatment formHCSA
  3. SOPHCSA clinical governance review procedureHCSA
  4. ChecklistHCSA inspection checklistHCSA

DOH, Abu Dhabi, United Arab Emirates

  1. PolicyDOH clinical records policyDOH
  2. Consent formDOH consent to treatment formDOH
  3. SOPDOH incident reporting and management procedureDOH
  4. ChecklistDOH audit checklistDOH

ORPHF, Hong Kong

  1. PolicyORPHF clinical records policyORPHF
  2. Consent formORPHF consent to treatment formORPHF
  3. SOPORPHF sentinel and serious untoward event procedureORPHF
  4. ChecklistORPHF inspection checklistORPHF

JCI, International, with the Gulf and Asia first

  1. PolicyJCI clinical records policyJCI
  2. Consent formJCI consent to treatment formJCI
  3. SOPJCI patient identification procedureJCI
  4. ChecklistJCI survey checklistJCI

Joint Commission, United States

  1. PolicyJoint Commission clinical records policyJoint Commission
  2. Consent formJoint Commission consent to treatment formJoint Commission
  3. SOPJoint Commission universal protocol procedureJoint Commission
  4. ChecklistJoint Commission survey checklistJoint Commission

AAAHC, United States

  1. PolicyAAAHC clinical records policyAAAHC
  2. Consent formAAAHC consent to treatment formAAAHC
  3. SOPAAAHC incident and near miss reporting procedureAAAHC
  4. ChecklistAAAHC survey checklistAAAHC

NSQHS and RACGP, Australia

  1. PolicyNSQHS and RACGP clinical records policyNSQHS and RACGP
  2. Consent formNSQHS and RACGP consent to treatment formNSQHS and RACGP
  3. SOPNSQHS and RACGP clinical handover procedureNSQHS and RACGP
  4. ChecklistNSQHS and RACGP assessment checklistNSQHS and RACGP

HIS, Scotland

  1. PolicyHIS clinical records policyHIS
  2. Consent formHIS consent to treatment formHIS
  3. SOPHIS adverse event reporting and learning procedureHIS
  4. ChecklistHIS inspection checklistHIS

HIW, Wales

  1. PolicyHIW clinical records policyHIW
  2. Consent formHIW consent to treatment formHIW
  3. SOPHIW concerns and incident management procedureHIW
  4. ChecklistHIW inspection checklistHIW
  5. PolicyHIW safeguarding policyHIW

RQIA, Northern Ireland

  1. PolicyRQIA clinical records policyRQIA
  2. Consent formRQIA consent to treatment formRQIA
  3. SOPRQIA incident reporting and learning procedureRQIA
  4. ChecklistRQIA inspection checklistRQIA
  5. PolicyRQIA safeguarding policyRQIA

MOPH, Qatar

  1. PolicyMOPH clinical records policyMOPH
  2. Consent formMOPH consent to treatment formMOPH
  3. SOPMOPH incident reporting and complaints procedureMOPH
  4. ChecklistMOPH inspection checklistMOPH

Kuwait MOH, Kuwait

  1. PolicyKuwait MOH clinical records policyKuwait MOH
  2. Consent formKuwait MOH consent to treatment formKuwait MOH
  3. SOPKuwait MOH medical error and complaint handling procedureKuwait MOH
  4. ChecklistKuwait MOH inspection checklistKuwait MOH

NHRA, Kingdom of Bahrain

  1. PolicyNHRA clinical records policyNHRA
  2. Consent formNHRA consent to treatment formNHRA
  3. SOPNHRA sentinel event reporting and investigation procedureNHRA
  4. ChecklistNHRA inspection checklistNHRA

Oman MOH, Sultanate of Oman

  1. PolicyOman MOH clinical records policyOman MOH
  2. Consent formOman MOH consent to treatment formOman MOH
  3. SOPOman MOH four-monthly self assessment procedureOman MOH
  4. ChecklistOman MOH inspection checklistOman MOH

HAS, France

  1. PolicyHAS clinical records policyHAS
  2. Consent formHAS consent to treatment formHAS
  3. SOPHAS eigs declaration and learning procedureHAS
  4. ChecklistHAS certification visit checklistHAS

HIQA, Ireland

  1. PolicyHIQA clinical records policyHIQA
  2. Consent formHIQA consent to treatment formHIQA
  3. SOPHIQA patient-safety incident reporting and open disclosure procedureHIQA
  4. ChecklistHIQA inspection checklistHIQA

Canada, Ontario, British Columbia and Quebec, Canada

  1. PolicyCanada clinical records policyCanada
  2. Consent formCanada consent to treatment formCanada
  3. SOPCanada patient-safety incident reporting and disclosure procedureCanada
  4. ChecklistCanada inspection checklistCanada

Ngā Paerewa, Aotearoa New Zealand

  1. PolicyNgā Paerewa clinical records policyNgā Paerewa
  2. Consent formNgā Paerewa consent to treatment formNgā Paerewa
  3. SOPNgā Paerewa incident reporting and complaints procedureNgā Paerewa
  4. ChecklistNgā Paerewa audit checklistNgā Paerewa

Swiss cantonal licensing, Zurich and Geneva, Switzerland

  1. PolicySwiss cantonal licensing clinical records policySwiss cantonal licensing
  2. Consent formSwiss cantonal licensing consent to treatment formSwiss cantonal licensing
  3. SOPSwiss cantonal licensing incident reporting and complaint procedureSwiss cantonal licensing
  4. ChecklistSwiss cantonal licensing inspection checklistSwiss cantonal licensing

NABH, India

  1. PolicyNABH clinical records policyNABH
  2. Consent formNABH consent to treatment formNABH
  3. SOPNABH incident reporting and quality improvement procedureNABH
  4. ChecklistNABH assessment checklistNABH

MOH and MSQH, Malaysia

  1. PolicyMOH and MSQH clinical records policyMOH and MSQH
  2. Consent formMOH and MSQH consent to treatment formMOH and MSQH
  3. SOPMOH and MSQH incident reporting and complaints procedureMOH and MSQH
  4. ChecklistMOH and MSQH survey checklistMOH and MSQH

QM-RL, Germany

  1. PolicyQM-RL clinical records policyQM-RL
  2. Consent formQM-RL consent to treatment formQM-RL
  3. SOPQM-RL error reporting and risk management procedureQM-RL
  4. ChecklistQM-RL inspection checklistQM-RL

Spanish autorización sanitaria, Madrid and Cataluña, Spain

  1. PolicySpanish autorización sanitaria clinical records policySpanish autorización sanitaria
  2. Consent formSpanish autorización sanitaria consent to treatment formSpanish autorización sanitaria
  3. SOPSpanish autorización sanitaria incident reporting procedureSpanish autorización sanitaria
  4. ChecklistSpanish autorización sanitaria inspection checklistSpanish autorización sanitaria

IGJ, the Netherlands

  1. PolicyIGJ clinical records policyIGJ
  2. Consent formIGJ consent to treatment formIGJ
  3. SOPIGJ incident and calamiteit reporting procedureIGJ
  4. ChecklistIGJ inspection checklistIGJ

HPCSA and OHSC, South Africa

  1. PolicyHPCSA and OHSC clinical records policyHPCSA and OHSC
  2. Consent formHPCSA and OHSC consent to treatment formHPCSA and OHSC
  3. SOPHPCSA and OHSC adverse event and complaints procedureHPCSA and OHSC
  4. ChecklistHPCSA and OHSC inspection checklistHPCSA and OHSC

GAHAR, Egypt

  1. PolicyGAHAR clinical records policyGAHAR
  2. Consent formGAHAR consent to treatment formGAHAR
  3. SOPGAHAR incident and sentinel event reporting procedureGAHAR
  4. ChecklistGAHAR inspection checklistGAHAR

MHLW, Japan

  1. PolicyMHLW clinical records policyMHLW
  2. Consent formMHLW consent to treatment formMHLW
  3. SOPMHLW medical safety and incident reporting procedureMHLW
  4. ChecklistMHLW inspection checklistMHLW

KOIHA, South Korea

  1. PolicyKOIHA clinical records policyKOIHA
  2. Consent formKOIHA consent to treatment formKOIHA
  3. SOPKOIHA incident and data breach reporting procedureKOIHA
  4. ChecklistKOIHA inspection checklistKOIHA

ANVISA, CFM and ONA, Brazil, worked through São Paulo and Rio de Janeiro

  1. PolicyANVISA, CFM and ONA clinical records policyANVISA, CFM and ONA
  2. Consent formANVISA, CFM and ONA consent to treatment formANVISA, CFM and ONA
  3. SOPANVISA, CFM and ONA adverse event reporting procedureANVISA, CFM and ONA
  4. ChecklistANVISA, CFM and ONA inspection checklistANVISA, CFM and ONA

The work these documents describe

  1. ProductThe AI medical scribe for clinics
  2. ProductBilling and insurance claims, from the signed note
  3. ProductAppointments, reminders and fewer missed visits
  4. ProductPatient follow-up and recalls, approved by a clinician
  5. ProductPatient messaging across WhatsApp, email and calls
  6. ProductThe evidence library your regulator asks for

In wai, the records your policies depend on are versioned and signed.

Notes, letters, consent forms and the audit trail, on your own clinic, in a 15 minute video call.

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