| Date | Site of audit | Number of entries submitted | Is there a results chart in the inpatient notes? | Is the results chart part of the admission form? | If it is a standalone form, does it have patient’s… | Are there results in the results charts? | Are the results legible? | Are the results dated? | If dated, are they written in consecutive order? | Are the dangerously abnormal results commented on… | Anything else observed? |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 06/03/2025 | CMH Wards | 10 | Yes:10 No:0 |
Yes:10 No:0 |
Yes:3 No:7 |
Yes:9 No:1 |
Fully legible:7 Some results difficult to read:3 Most results difficult to read:0 Completely illegible:0 |
Yes:9 No:1 |
Yes:7 No:3 |
Yes:7 No:3 |
Patient was admitted for 2 days without any results written but stickers were present on the admission., Great example of an ideal results chart and results were acted on, the same day as when they were traced., results written in both admission pack sheet and a stand-alone sheet, N/A |
| 15/08/2024 | CMH Wards | 10 | Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Fully legible:8 Some results difficult to read:2 Most results difficult to read:0 Completely illegible:0 |
Yes:9 No:1 |
Yes:10 No:0 |
Yes:10 No:0 |
|
| 08/05/2024 | CMH Wards | 10 | Yes:10 No:0 |
Yes:10 No:0 |
Yes:0 No:10 |
Yes:10 No:0 |
Fully legible:9 Some results difficult to read:1 Most results difficult to read:0 Completely illegible:0 |
Yes:10 No:0 |
Yes:8 No:2 |
Yes:10 No:0 |
Not all results of full blood count filled in, Some results missing a date, Some results missing dates, Some results missing dates, Some results missing a date, Some results of full blood count not recorded, Some results missing dates |
| 29/01/2024 | CMH Wards | 13 | Yes:13 No:0 |
Yes:13 No:0 |
Yes:13 No:0 |
Yes:13 No:0 |
Fully legible:5 Some results difficult to read:5 Most results difficult to read:3 Completely illegible:0 |
Yes:12 No:1 |
Yes:11 No:2 |
Yes:10 No:3 |
The results for laboratory investigations (urine findings) not listed (ie. not typed) were not dated, Not all results were dated (results written below in the additional section were not dated), This lab results sheet contained multiple large sections which were crossed out rendering alongside results difficult to decipher, Hyponatraemia not mentioned in inpatient notes, The recording of the lab results on this chart was started in the middle of the chart leaving wasted space to the left and limiting the entries to the right., Elevated CRP not commented on in the notes. The recording of the lab results on this chart was started in the middle of the chart leaving wasted space to the left and limiting the entries to the right, This results sheet was difficult to read and had been crossed out multiple times., Raised CRP to commented on in inpatient notes. Untidily crossed out sections hence difficulty discerning certain sections. |
| 02/06/2023 | CMH Wards | 10 | Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:9 No:1 |
Fully legible:8 Some results difficult to read:1 Most results difficult to read:0 Completely illegible:1 |
Yes:9 No:1 |
Yes:9 No:1 |
Yes:0 No:10 |
|
| 02/03/2023 | CMH MOPD | 8 | Yes:8 No:0 |
Yes:7 No:1 |
Yes:7 No:1 |
Yes:8 No:0 |
Fully legible:6 Some results difficult to read:2 Most results difficult to read:0 Completely illegible:0 |
Yes:8 No:0 |
Yes:8 No:0 |
Yes:6 No:2 |
eGFR is not charted with the CUSP results, Urine Lam results not charted in the result chart. |