Baseline data of record-keeping standards (in %)
Standard | Description | May 2017 | December 2017 | May 2018 | April 2019 | July 2019 |
2 | No. of pages with first and last name | 49 | 57 | 56 | 58 | 100 |
No. of pages with hospital identification/NHS number | 42 | 42 | 46 | 51 | 100 | |
3 | No. of pages with standardised structure/layout | 93 | 100 | 100 | 100 | 100 |
4 | No. admissions filed in chronological order | 90 | 100 | 90 | 90 | 100 |
5 | Admission/clerking proforma completed | 60 | 70 | 70 | 90 | 100 |
Discharge letter present | 90 | 100 | 100 | 100 | 100 | |
Proforma correctly completed | 80 | 90 | 100 | 100 | 100 | |
6 | Date recorded | 87 | 96 | 92 | 100 | 100 |
Time recorded | 88 | 87 | 82 | 84 | 100 | |
Printed name/signature | 49 | 62 | 64 | 87 | 100 | |
Printed grade | 51 | 34 | 50 | 76 | N/A | |
8 | Most senior person recorded | 75 | 53 | 47 | 37 | 100 |
N/A, Not Applicable; NHS, National Health Service.