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Inpatient daily notes audit – CMH Internal Medicine (previous results)

Date Site of audit Number of entries submitted Patient identifiers present on the page Time recorded on note? Date recorded on note? Is the note easily legible? Are the key issues clearly identified? Is there a clear statement of what was done? Is there a clear management plan? Is the note signed? Is the author identifiable? Number of words in the clinical note? Anything else observed?
04/02/2025 CMH Wards 10 Yes:4
No:6 		Yes:7
No:3 		Yes:10
No:0 		Fully legible: 8
Few items difficult to read: 1
Somewhat legible: 1
Mostly difficult to read: 0
Completely illegible: 0		 Yes:7
No:3 		Yes:9
No:1 		Yes:9
No:1 		Yes:10
No:0 		Yes:6
No:4 		Average:42.2
Maximum:67
Minimum:28
Median:44 		Half the vitals filled in. No BP; no temperature; no respiratory rate, No assessment recorded after systems examination. Launches straight into plan., Use of prescriber number instead of practitioner number on daily notes, D/C today without indication of medication to d/c on, indication of medium-to-long term follow up plan
10/07/2024 CMH Wards 13 Yes:13
No:0 		Yes:13
No:0 		Yes:13
No:0 		Fully legible: 9
Few items difficult to read: 4
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:11
No:2 		Yes:8
No:5 		Yes:13
No:0 		Yes:12
No:1 		Yes:8
No:5 		Average:82.08
Maximum:195
Minimum:28
Median:74 		This note said HAA (history as above) and the last time the problems had been written down was 4 pages back and 2 days previously, This was a HAA( history as above) note but all patient and condition details were clearly visible on the adjoining page
23/05/2024 CMH Wards 10 Yes:8
No:2 		Yes:8
No:2 		Yes:9
No:1 		Fully legible: 7
Few items difficult to read: 2
Somewhat legible: 1
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:8
No:2 		Yes:10
No:0 		Yes:10
No:0 		Yes:6
No:4 		Average:54.5
Maximum:113
Minimum:0
Median:49 		72
31/10/2023 CMH Wards 10 Yes:9
No:1 		Yes:7
No:3 		Yes:10
No:0 		Fully legible: 7
Few items difficult to read: 2
Somewhat legible: 1
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Yes:9
No:1 		Yes:7
No:3 		Average:59.6
Maximum:184
Minimum:25
Median:35 		No mention of where the patient was seen, key issues were mentioned on the overleaf of the note for this day but not in the latest note
29/06/2023 CMH MOPD 10 Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Fully legible: 9
Few items difficult to read: 1
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Yes:9
No:1 		Average:28.5
Maximum:45
Minimum:0
Median:30 		none, none, none, no, none, none, none, none, none, none
07/03/2023 CMH Wards 1 Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Fully legible: 0
Few items difficult to read: 0
Somewhat legible: 1
Mostly difficult to read: 0
Completely illegible: 0		 Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Average:35
Maximum:35
Minimum:35
Median:35 		This clinician has not written ji
07/03/2023 CMH MOPD 9 Yes:6
No:3 		Yes:5
No:4 		Yes:9
No:0 		Fully legible: 4
Few items difficult to read: 3
Somewhat legible: 2
Mostly difficult to read: 0
Completely illegible: 0		 Yes:8
No:1 		Yes:6
No:3 		Yes:8
No:1 		Yes:9
No:0 		Yes:3
No:6 		Average:57.78
Maximum:120
Minimum:30
Median:40