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Details documented (%), n = 200
| Demographic details | Clinical details | ||
|---|---|---|---|
| Name | 190 (95) | Diagnosis | 176 (88) |
| Medical record no. | 138 (69) | Prescription | 176 (88) |
| Date of birth | 0 (0) | Discharge instructions | 176 (88) |
| Sex | 158 (79) | Investigation values | 30 (15) |
| Date of visit | 168 (84) | Follow-up advice | 14 (7) |
| Postal code | 2 (1) | Doctor’s signature | 178 (89) |
| Patient’s signature | 160 (80) | ||
