Content inadequate because: | ||||
Record components | Inadequate (%) | Illegible (%) | Incomplete (%) | Other (%) |
Nursing record (n=7926) | 9.6 | NM | NM | NM |
Physician orders | 10.1 | 2.4 | 5.3 | 2.4 |
Medication list (if applicable) | 13.9 | 1.2 | 10.7 | 2.0 |
Medical record (n=5171)* | 23.4 | 7.7 | 14.8 | 0.9 |
Report of medical history and physical examination at admission | 12.4 | 3.9 | 7.6 | 0.9 |
Discharge letter | 5.2 | NM | NM | NM |
If applicable: | ||||
Procedure reports | 2.3 | |||
Diagnostic imaging results | 1.2 | |||
Laboratory/pathology–anatomy reports/test results | 2.3 | NM | NM | NM |
↵* The nurses reviewed the quality of 5171 medical records. In case the nurses found enough screening criteria in the nursing record, they did not screen the whole medical record.
NM, not measured.