Table 1.
Classification of examined indices based on the minimum score obtained by 200 subjects
| No. | Index of concern in records | White | Incomplete | Illegible | Complete |
|---|---|---|---|---|---|
| 1 | The full demographic information of patients (name, age, place of birth, date of birth) appears on the file cover, and all information is completely documented. | 0 | 100 | 12 | 99 |
| 2 | File documents are arranged by the order issued by the Medical Documents Center (admission letter, physician’s prescriptions, nursing reports, para-clinical tests, content letter, history, and patient training). | 0 | 186 | 0 | 14 |
| 3 | All documents on para-clinical measures are attached and checked according to the date in the relevant file. | 1 | 175 | 1 | 23 |
| 4 | A physician’s instructions along with the number of items in letters and the time and date come with a signature. | 0 | 183 | 8 | 9 |
| 5 | A physician’s instructions are terminated with a straight underline so that nothing more can be added. | 0 | 180 | 0 | 20 |
| 6 | Vital signs are accurately recorded in specified fields on a chart sheet in red (temperature), blue (pulse), black (blood pressure), and green (breath). | 3 | 161 | 2 | 34 |
| 7 | The information requested is completely and accurately documented in tables below the vital signs chart. | 4 | 190 | 0 | 6 |
| 8 | The intervals for checking vital signs registered on a patient’s chart sheet should be consistent with the instructions written in the corresponding file. | 3 | 182 | 0 | 12 |
| 9 | Nursing reports are legible with mistakes. | 3 | 81 | 65 | 51 |
| 10 | Nursing reports are written in succession with no blank spaces among them. | 0 | 105 | 1 | 94 |
| 11 | Nursing reports are signed and contain the name of the nurse in charge, his/her position, and documentation time. | 0 | 13 | 15 | 172 |
| 12 | If there is a mistake in the nursing report, it must be marked and then signed and stamped. | 0 | 20 | 0 | 171 |
| 13 | The exact time of specific measures (tests, radiography, physician’s visits) is indicated. | 124 | 40 | 33 | 3 |
| 14 | Ambiguous words, such as “good,” “normal,” and “medium,” are not used in the report. | 0 | 42 | 39 | 119 |
| 15 | In the nursing report, the cause, type of disease, and type of referral are mentioned. | 0 | 106 | 0 | 94 |
| 16 | Only the abbreviations approved by the institute are used in medical records. | 0 | 131 | 28 | 41 |
| 17 | There are enough explanations about the general status of a patient (vital signs, level of consciousness, objective and subjective symptoms). | 197 | 3 | 0 | 0 |
| 18 | Sufficient explanations are provided about a patient’s excretion conditions (number of times, colour, consistency of symptoms and patient’s complaints). | 198 | 2 | - | - |
| 19 | The report is closing with a straight underline so that nothing more can be added. | 186 | 4 | 0 | 0 |
| 20 | The nutritional status of a patient is denoted with measurable benchmarks (amount of food, total food intake per day). | 198 | 2 | 0 | 0 |
| 21 | Notes on invasive treatments (urinary catheterisation, nasogastric tube, etc.) are provided, along with usage time, the instructor, patient response to the treatment, and follow-up points in the subsequent shift. | 9 | 141 | 37 | 13 |
| 22 | A patient’s training sheet is completed and signed according to the measures taken. | 193 | 6 | 0 | 1 |
| 23 | Nursing procedures, including nursing diagnosis, nursing interventions (a type of intervention, patient’s behaviour, intervention time), and evaluation of actions (patient’s response), are recorded in documentation reports. | 93 | 85 | 14 | 8 |
| 24 | Exact drug prescriptions are documented by mentioning the drug, consumption method, and timing of medication. A nurse’s signature should appear in the document. | 0 | 75 | 14 | 111 |
| 25 | Nursing diagnosis is written, and the nursing process is specified at the end of each assessment form. | 128 | 52 | 14 | 6 |
| 26 | The orders in a file accord with a physician’s instructions. | 0 | 119 | 10 | 71 |
| 27 | Patient’s profile, medical and nursing diagnosis are stored in the file. | 0 | 102 | 4 | 94 |
| 28 | Telephone orders are signed by two people, and the exact time is included. | 0 | 137 | 3 | 60 |
| 29 | A patient’s electrocardiography contains the patient’s profile and date and is attached to a special sheet. | 0 | 122 | 0 | 60 |
| 30 | Consent forms include explanations about the risks and benefits of treatment or surgical intervention, other treatment alternatives, and measures. It provides some evidence of the fact that a patient or his lawyer are fully satisfied with the surgery or treatment. | 8 | 157 | 13 | 22 |