Table 1.
Documentation standards | N | n (%) |
Record documented by clinicians within the first 24 h of admission | 732 | 721 (98.49) |
Nursing care plans documented within the first 24 h of admission | 732 | 627 (85.66) |
Patient's name properly documented on the first page of all continuation sheets | 732 | 551 (75.27) |
Unit number recorded on the first page of all continuation sheets | 732 | 431 (58.88) |
Progress notes documented each day | 732 | 672 (91.80) |
Progress notes signed and dated each day | 672 | 645 (95.98) |
Investigation order forms signed and dated | 732 | 528 (72.13) |