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Discharge letters audit – CMH Internal Medicine (previous results)

Date Site of audit Number of entries submitted Patient identifiers present? Date of letter present? Admission ward stated? Admission and discharge dates stated? Condition at admission and discharge circled? Diagnosis clear? ICD-10 codes stated? Management stated (more than just blood results)? Treatment logical? Follow-up stated? Letter legible? Author identifiable? Could this letter be used to safely manage the… Anything else observed?
25/06/2025 CMH MOPD 1 Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Yes:0
No:1 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Written on computer system:1
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:1
No:0 		Yes:0
No:1
03/06/2025 CMH Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:7
No:3 		Yes:9
No:1 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Yes:7
No:3 		Yes:9
No:1 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:8
No:2 		Yes:9
No:1
22/08/2024 CMH MOPD 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:7
No:3 		Yes:6
No:4 		Yes:0
No:10 		Yes:6
No:4 		Yes:9
No:1 		Yes:10
No:0 		Written on computer system:0
Fully legible:4
Some parts difficult to read:5
Mostly difficult to read:1
Completely illegible:0 		Yes:10
No:0 		Yes:6
No:4 		Author name not written in block letters, Numbers to indicate the state of the patient on admission and on discharge not used. Word descriptions used, Discharge diagnosis not written
12/03/2024 CMH Wards 10 Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Yes:5
No:5 		Yes:7
No:3 		Yes:0
No:10 		Yes:6
No:4 		Yes:6
No:4 		Yes:9
No:1 		Written on computer system:0
Fully legible:5
Some parts difficult to read:2
Mostly difficult to read:3
Completely illegible:0 		Yes:8
No:2 		Yes:5
No:5 		Author name identifiable but not written in block letters, No diagnosis at discharge, Author name not in block letters, no diagnosis at discharge, No discharge diagnosis, Follow up site provided with no follow up date.
22/02/2024 CMH MOPD 7 Yes:6
No:1 		Yes:7
No:0 		Yes:6
No:1 		Yes:7
No:0 		Yes:4
No:3 		Yes:4
No:3 		Yes:0
No:7 		Yes:7
No:0 		Yes:7
No:0 		Yes:6
No:1 		Written on computer system:0
Fully legible:6
Some parts difficult to read:1
Mostly difficult to read:0
Completely illegible:0 		Yes:7
No:0 		Yes:7
No:0