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Inpatient daily notes audit – Frere 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?
19/03/2026 Frere Wards 1 Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Fully legible: 0
Few items difficult to read: 1
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Average:37
Maximum:37
Minimum:37
Median:37 		No
19/03/2026 Frere MOPD 10 Yes:6
No:4 		Yes:10
No:0 		Yes:10
No:0 		Fully legible: 3
Few items difficult to read: 1
Somewhat legible: 1
Mostly difficult to read: 5
Completely illegible: 0		 Yes:5
No:5 		Yes:5
No:5 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Average:29
Maximum:50
Minimum:7
Median:28 		No, History as above and ward not indicated, No, No vitals. No examinations, Physical examination omitted, Physical examination omitted, Physical examination omitted, No, No, Physical examination omitted no vitals
22/05/2025 Frere Wards 1 Yes:0
No:1 		Yes:0
No:1 		Yes:1
No:0 		Fully legible: 1
Few items difficult to read: 0
Somewhat legible: 0
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:1
No:0 		Average:80
Maximum:80
Minimum:80
Median:80 		One page did not have patient identifiers and one entry of notes did not have the time recorded
22/05/2025 Frere Wards 10 Yes:6
No:4 		Yes:8
No:2 		Yes:10
No:0 		Fully legible: 4
Few items difficult to read: 5
Somewhat legible: 1
Mostly difficult to read: 0
Completely illegible: 0		 Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:5
No:5 		Average:54
Maximum:80
Minimum:40
Median:45 		One page didn’t have patient identifiers and 1 entry did not have the time recorded. Time of CWR was also not recorded. The location was not recorded, Practitioner number not included. “History as above ” is written on every subsequent entry (multiple pages) after the initial entry. The first name was continuously left out on the identifiers, Practitioner number not included but name is present., No patient identifiers present., No times recorded. CWR notes were the only entry on some days and these only included further management plan and not much info on clinical condition or key issues, Pharmacy number written instead of practitioner number., No name or practitioner number. Very few CWR noted and far apart, Location not included, Pharmacy number written instead of practitioner number. No doctor identifier written. No CWR noted
27/02/2025 Frere Wards 10 Yes:5
No:5 		Yes:1
No:9 		Yes:10
No:0 		Fully legible: 5
Few items difficult to read: 3
Somewhat legible: 1
Mostly difficult to read: 1
Completely illegible: 0		 Yes:9
No:1 		Yes:9
No:1 		Yes:10
No:0 		Yes:9
No:1 		Yes:6
No:4 		Average:29.8
Maximum:46
Minimum:17
Median:28 		Plan included something already done by Occupational therapist
16/10/2024 Frere Wards 10 Yes:8
No:2 		Yes:8
No:2 		Yes:10
No:0 		Fully legible: 4
Few items difficult to read: 3
Somewhat legible: 2
Mostly difficult to read: 1
Completely illegible: 0		 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Yes:8
No:2 		Average:126.8
Maximum:180
Minimum:65
Median:131
22/08/2024 Frere Wards 14 Yes:10
No:4 		Yes:13
No:1 		Yes:14
No:0 		Fully legible: 5
Few items difficult to read: 6
Somewhat legible: 1
Mostly difficult to read: 2
Completely illegible: 0		 Yes:13
No:1 		Yes:11
No:3 		Yes:14
No:0 		Yes:13
No:1 		Yes:5
No:9 		Average:91.29
Maximum:200
Minimum:15
Median:85 		No examination done, only vitals written
14/08/2024 Frere Wards 10 Yes:6
No:4 		Yes:9
No:1 		Yes:10
No:0 		Fully legible: 6
Few items difficult to read: 4
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Average:87.2
Maximum:175
Minimum:50
Median:73
25/04/2024 Frere Wards 10 Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Fully legible: 1
Few items difficult to read: 7
Somewhat legible: 2
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:1
No:9 		Average:93.4
Maximum:250
Minimum:28
Median:73 		MP number missing, Illegible hand writing, MP number missing, pt no day note made, Small handwriting, MP number missing, date and time not on all pages., No MP number, No MP number, No time at all, No surname, no MP number, Surnam written but illegible
24/08/2023 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Fully legible: 8
Few items difficult to read: 2
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Average:155.4
Maximum:171
Minimum:138
Median:154.5 		None
21/06/2023 Frere Wards 10 Yes:5
No:5 		Yes:7
No:3 		Yes:10
No:0 		Fully legible: 6
Few items difficult to read: 4
Somewhat legible: 0
Mostly difficult to read: 0
Completely illegible: 0		 Yes:7
No:3 		Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Yes:7
No:3 		Average:29.5
Maximum:44
Minimum:11
Median:29.5 		No, No, No, No, No, No, No, No, No, No
11/04/2023 Frere Wards 10 Yes:10
No:0 		Yes:8
No:2 		Yes:10
No:0 		Fully legible: 2
Few items difficult to read: 3
Somewhat legible: 3
Mostly difficult to read: 2
Completely illegible: 0		 Yes:8
No:2 		Yes:10
No:0 		Yes:10
No:0 		Yes:9
No:1 		Yes:4
No:6 		Average:104.7
Maximum:175
Minimum:50
Median:102.5