Table 1.

Score sheet used to assess patient notes before and after implementation of the proforma.

Criteria	YES/NO
Hospital Record
Date of Admission
Time of Admission
NHS Number
Address and Postcode
Date of Birth
Next of Kin
Occupation
Marital Status
Registered GP
Details of Clinical Record
Presenting complaint
History of Presenting Complaint
Full Medication History
Examination Findings
Patients height
Patients weight
Working diagnosis
Medical/Surgical Plan