Table 2 Inpatient Record Checklist

Admission notes (25%)

1. Present illness is clear, chronologically arranged, and segmented; the records are complete and correct.

8

7

6

0

2. Positive findings in ‘review of system’ should be specified in detail.

5

4

3

0

3. Physical examination is consistent with the symptoms of the disease and corresponds to the diagnosis and treatment plan.

7

6

5

0

4. ‘Education plan’ records prevention programmes rather than treatment plans.

5

4

3

0

Problems list (8%)

5. Daily admission problems are recorded properly and completely.

4

3

2

0

6. The content of the problems list corresponds to the progress record.

4

3

2

0

Progress notes (25%)

7. The course record does not have a copy-and-paste format or repeated typing errors.

7

6

5

0

8. Describe the treatment and the symptoms, which are compared to those in the previous days. Record the differences between new and old laboratory data, e.g. the antibiotic treatment days, days after surgery, and radiation therapy.

3

2

1

0

9. Record new changes in the problem or condition, followed by revised diagnosis and treatment plans.

6

5

4

0

10. No duplications of objective information, which recorded experimental data, image inspection, etc. in ‘assessments’. Note: important data are allowed to be duplicated in daily records. Serial data should be shown in brief.

3

2

1

0

11. The plan contains indications for important laboratory tests, ranges of value, image, and other study findings. Also include the corresponding plans to those tests results.

3

2

1

0

12. The invasive procedure or the surgical procedure is comprehensively recorded (the surgical record containing the intraoperative image, or the plotter is rated as ‘excellent’).

3

2

1

0

Weekly summary (4%)

13. The record is concise and includes admission date, main diagnosis and reasons for admission, procedures during the past 1 week, disease course and responses to treatments, plans for the following week (not copying admission note).

4

3

2

0

Discharge notes (25%)

14. The discharge diagnosis is comprehensive. No informal abbreviations are present. The diagnosis is written in order of importance and includes comorbidities.

(If there is any operation record, the pre-operative, post-operative diagnosis and the term of the surgery procedures should be correct and comprehensive).

8

7

6

0

15. The content of the discharge summary is concise, brief, and logical.

5

4

3

0

16. Examination results, including laboratory data, images, electrocardiogram, pathology, special examination, etc., are summarised without redundant contents (e.g. a full copy of examination reports with content unrelated to the discharge diagnosis).

4

3

2

0

17. The discharge summary is revised according to attending physicians’ feedback in admission medical records. Any error in the admission notes should have been corrected by the attending physician and should not re-appear in the discharge notes.

8

7

6

0

Overall performance (13%)

18. Assessment, differential diagnosis, and treatment plans are logical and reasonable.

5

4

3

0

19. Electronic medical records (EMRs) are written consistently without informal symbols, characters, or abbreviation.

4

3

2

0

20. The descriptions are clear. No grammatical or spelling errors are present.

4

3

2

0

Outstanding performance

21. The therapeutic plan includes shared decision-making (SDM) meeting records and/or conference records on treatment plans with patients and families

22. There is an evidence-based record, with literature review, for rare cases.

23. The results are summarised in a case conference, a combined conference, or a grand round in EMRs.