Table 2.

Clinical detailing and quality assurance

Documentation standards	N	n (%)
Record contains past medical history	732	642 (87.70)
Provisional diagnosis documented in the records	732	690 (94.26)
Discharge notes recorded	732	640 (87.43)
Discharge summary completed	732	94 (12.84)
Discharge summary contains summary of hospitalization	94	90 (95.74)
Discharge summary contains information on treatment and medication administered	94	89 (94.68)
Discharge summary contains follow-up details	94	88 (93.62)