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)