A.	PATIENT’S DETAILS (on each page)	NC = 0	PC = 1	C = 2	NA	COMMENTS	15
1.	Name―Initials
2.	Age/DoB
3	Hospital number
4.	Ward or Outpatient Department
5.	The responsible doctor is identified on each page
B.	DOCUMENTATION	NC = 0	PC = 1	C = 2	NA	COMMENTS	150
1.	All appropriate patient details are recorded on admission form or outpatient registration
2.	Time of Admission to ward or outpatient department is recorded
3.	Date & time of first consultation on ward outpatient clinic is recorded
4.	First consultation is within the expected time frame
5.	Medical history, including psychosocial history
6.	Medical examination
7.	Patient allergies and risk factors are clearly identified
8.	Details of medical findings leading to a diagnosis are recorded
9.	Requests for diagnostic tests
10.	Results of diagnostic tests
11.	Drs’ signature on results of investigations
12.	Medical treatment prescribed, in notes and on prescription sheets
13.	Prescription sheet is correctly completed
14.	Record of every consultation is evident
15.	The admission nursing assessment is completed within the required time frame
16.	Record of consultation with other clinical support services: Physio, social worker, etc.
17.	All entries are labelled, e.g. “Doctor’s Note”
18.	Each entry is dated, timed and in chronological order
19.	Entries are legible
20.	Only approved abbreviations are used
21.	Nutritional needs are detailed as required
22.	Legible signature and status included on every entry
23.	Referral letters and degree of urgency (Internal only)
24.	Interdisciplinary communication is documented
25.	All nursing charts are correctly completed
C.	INFORMATION FOR PATIENTS	NC = 0	PC = 1	C = 2	NA	COMMENTS	25
1.	Patient and/or carer are fully informed of findings
2.	Patient and/or carer is aware of appropriate options for treatment
3.	Patient and/or Carer participated in decision-making relating to treatment
4.	Patient education is documented
5.	Informed consent was sought and given for interventional procedures