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. 2021 Feb 15;10(1):e000918. doi: 10.1136/bmjoq-2020-000918

Table 1.

Baseline data of record-keeping standards (in %)

Standard Description May 2017 December 2017 May 2018 April 2019 July 2019
2 No. of pages with first and last name 49 57 56 58 100
No. of pages with hospital identification/NHS number 42 42 46 51 100
3 No. of pages with standardised structure/layout 93 100 100 100 100
4 No. admissions filed in chronological order 90 100 90 90 100
5 Admission/clerking proforma completed 60 70 70 90 100
Discharge letter present 90 100 100 100 100
Proforma correctly completed 80 90 100 100 100
6 Date recorded 87 96 92 100 100
Time recorded 88 87 82 84 100
Printed name/signature 49 62 64 87 100
Printed grade 51 34 50 76 N/A
8 Most senior person recorded 75 53 47 37 100

N/A, Not Applicable; NHS, National Health Service.