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Discharge letters audit – Frere 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?
17/02/2026 Frere Wards 13 Yes:13
No:0 		Yes:13
No:0 		Yes:13
No:0 		Yes:13
No:0 		Yes:8
No:5 		Yes:12
No:1 		Yes:13
No:0 		Yes:12
No:1 		Yes:13
No:0 		Yes:12
No:1 		Written on computer system:13
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:13
No:0 		Yes:13
No:0 		Presenting symptoms not stated, examination findings not stated if at admission or at discharge. Blood bar codes written, but not stated if normal or deranged. Follow up for other disciplines not clearly stated (where, when). Include even if verbally discussed, No blood results or cxray findings (resp pt), Weight written for tb tto, Prescriber number and practice number not written (change on computer), no date on dc summary for mopd date (just 1/12), examination finding, Follow up at local clinic but reason not clear, examination finding not stated if at admission or discharge, Presenting complaints not noted and pt condition not stated (on admission or discharge), examination not clear if at discharge or admission, No prescriber number, No prescriber number, No prescriber number or registration number (maybe manually written), No date of mopd review
13/10/2025 Frere Wards 1 Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		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:1
No:0
13/10/2025 Frere Wards 1 Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		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:1
No:0
13/10/2025 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:4
No:6 		Yes:7
No:3 		Yes:5
No:5 		Yes:5
No:5 		Yes:7
No:3 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:7
No:3 		Admission diagnosis stated but no real comment on condition., No note on progression of clinical status in ward., Pt was admitted for a whole month but only one sentence on clinical course/in-pt management., No medications or doses stated that pt is on for his multiple comorbidities. No information alluding to severity of different comorbidities like HbA1C, whether pt is insulin-dependent, type 2 or type 1.
14/08/2025 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:5
No:5 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:10
No:0
06/06/2025 Frere MOPD 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:9
No:1 		Yes:6
No:4 		Yes:9
No:1 		Yes:9
No:1 		Yes:8
No:2 		Yes:9
No:1 		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:10
No:0 		Yes:8
No:2
27/03/2025 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:4
No:6 		Yes:9
No:1 		Yes:9
No:1 		Yes:10
No:0 		Yes:8
No:2 		Yes:9
No:1 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:9
No:1
08/10/2024 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Yes:10
No:0 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:9
No:1
12/09/2024 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:6
No:4 		Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Yes:8
No:2 		Yes:9
No:1 		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:10
No:0 		Yes:8
No:2
31/05/2024 Frere Wards 1 Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:0
No:1 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Yes:1
No:0 		Written on computer system:0
Fully legible:1
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:1
No:0 		Yes:1
No:0
31/05/2024 Frere Wards 11 Yes:11
No:0 		Yes:11
No:0 		Yes:11
No:0 		Yes:11
No:0 		Yes:7
No:4 		Yes:11
No:0 		Yes:11
No:0 		Yes:11
No:0 		Yes:11
No:0 		Yes:11
No:0 		Written on computer system:0
Fully legible:11
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:11
No:0 		Yes:11
No:0
16/08/2023 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:10
No:0
16/08/2023 Frere Wards 10 Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Yes:10
No:0 		Yes:7
No:3 		Yes:10
No:0 		Yes:10
No:0 		Written on computer system:10
Fully legible:0
Some parts difficult to read:0
Mostly difficult to read:0
Completely illegible:0 		Yes:10
No:0 		Yes:10
No:0
19/05/2023 Frere Wards 10 Yes:10
No:0 		Yes:9
No:1 		Yes:10
No:0 		Yes:3
No:7 		Yes:10
No:0 		Yes:8
No:2 		Yes:10
No:0 		Yes:8
No:2 		Yes:8
No:2 		Yes:8
No:2 		Written on computer system:1
Fully legible:6
Some parts difficult to read:1
Mostly difficult to read:0
Completely illegible:2 		Yes:10
No:0 		Yes:7
No:3 		no, no