Table 1.

Level of Documentation and Interventions Included in Patients’ Medical Records

Characteristic	No. (%) of Records* (n = 779)
Level of documentation†
Extensive	81 (10.4)
Sufficient	432 (55.5)
Minimal	131 (16.8)
Intervention documented in the prescription section
Verbal orders
Records with ≥ 1 verbal order	142 (18.2)
No. of verbal orders per record (median and IQR)	1 (1–2)
Suggestions
Records with ≥ 1 suggestion	369 (47.4)
No. of suggestions per record (median and IQR)	1 (1–2)
Verbal orders and/or suggestions
Records with ≥ 1 verbal order or suggestion (or both)	426 (54.7)

IQR = interquartile range.

^*Except where indicated otherwise.

^†Extensive documentation was defined as presence of ≥ 1 admission, follow-up, or discharge note for hospital stays ≤ 2 days; an admission note and a discharge note for hospital stays of 3–6 days; or an admission note, a follow-up note, and a discharge note for hospital stays ≥ 7 days. Sufficient documentation was defined as presence of ≥ 1 note in medical section of patient’s medical record, regardless of the patient’s length of stay in hospital. Minimal documentation was defined as ≥ 1 written intervention in patient’s medical record, such as a note in the medical section or a suggestion or verbal order in the prescription section.