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Observations charts audit – CMH Internal Medicine (previous results)

Date Site of audit Number of entries submitted Patient identifiers present? Observations orders circled? Observations orders signed? Observation frequency – number of temperatures… If observations order signed, does temperature… Observation frequency – number of BPs recorded on… If observations order signed, does BP frequency on… Do temperature and pulse rate follow each other? Resuscitation status recorded on chart? Anything else observed?
04/07/2024 CMH Wards 10 Yes:10
No:0		 Yes:0
No:10		 Yes:0
No:10		 Entries:2, 2, 1, 2, 1, 1, 2, 2, 5, 4

Average:2.2
Maximum:5
Minimum:1
Median:2

 Yes:10
No:0		 Entries:2, 2, 1, 2, 1, 1, 2, 2, 5, 4

Average:2.2
Maximum:5
Minimum:1
Median:2

 Yes:10
No:0		 Yes:9
No:0
Insufficient recordings:1		 Yes:0
No:10		 Patient identifiers only noted on first observation chart, Days missing from chart where no vitals recorded, Vitals plotted on EWS chart making it very clear to see and follow trend, Vitals plotted on EWS chart making it very clear to see and follow trend
26/05/2023 CMH Wards 10 Yes:10
No:0		 Yes:0
No:10		 Yes:8
No:2		 Entries:6, 6, 2, 3, 4, 4, 2, 2, 1, 2

Average:3.2
Maximum:6
Minimum:1
Median:2.5

 Yes:10
No:0		 Entries:6, 6, 2, 3, 4, 4, 2, 2, 1, 2

Average:3.2
Maximum:6
Minimum:1
Median:2.5

 Yes:10
No:0		 Yes:10
No:0
Insufficient recordings:0		 Yes:1
No:9