Variable | Documentation status | |||
History taking | ||||
| NO, n (%) | P, n (%) | FD, n (%) | NA, n (%) |
History of presenting complaint | 138 (27) | 222 (43) | 153 (30) | - |
Medical history | 295 (58) | 87 (17) | 131 (25) | - |
History of previous medication | 395 (77) | 58 (11) | 60 (12) | - |
History of allergies | 484 (94) | 15 (3) | 14 (3) | - |
Surgical history | 434 (85) | 38 (7) | 41 (8) | - |
Social history | 455 (89) | 20 (4) | 38 (7) | - |
Family history | 440 (87) | 23 (5) | 41 (8) | - |
Gynecological and obstetric history (female patients) | 155 (30) | 68 (13) | 54 (11) | 236 (46) |
Review of systems | 208 (40) | 281 (55) | 24 (5) | - |
Documentation of physical examination | ||||
General Appearance | 56 (11) | 248 (48) | 209 (41) | - |
Cardiovascular system | 211 (41) | 170 (33) | 132 (26) | - |
Nervous system | 409 (80) | 35 (7) | 69 (13) | - |
Genitourinary system | 396 (77) | 70 (14) | 47 (9) | - |
Musculoskeletal system | 476 (93) | 21 (4) | 16 (3) | - |
Diagnosis | ||||
Principal diagnosis | 38 (7) | 72 (14) | 403 (79) | - |
Plan | ||||
Plan of care | 23 (4) | 187 (38) | 302 (58) | - |
Interventions/implementation | ||||
Procedures/interventions recorded | 24 (4) | 187 (38) | 302 (58) | - |
Invasive procedures recorded | 72 (14) | 27 (5) | 40 (8) | 374 (73) |
Records | ||||
Record of examination before anesthesia | 86 (17) | 15 (3) | 38 (7) | 374 (73) |
Treatment records | 38 (7) | 109 (21) | 364 (71) | 2 (1) |
Investigation forms completed | 254 (50) | 89 (17) | 159 (31) | 11 (2) |
Discharge forms | 154 (30) | 301 (59) | 45 (9) | 13 (2) |
Quality improvement of the records | ||||
The documentation is legible | 15 (3) | 9 (2) | 489 (95) | - |
Date of record entry | 25 (5) | 30 (6) | 458 (89) | - |
Integration of doctors’ and nurses’ documentation in the records | 239 (47) | 236 (46) | 38 (7) | - |
Name of the doctor indicated | 29 (6) | 176 (34) | 308 (60) | - |
Title of the doctor | 455 (89) | 41 (8) | 17 (3) | - |
Errors erased with a single line | 15 (3) | 20 (4) | 11 (2) | 467 (91) |