AE Documentation and Prescribing Practice Audit Online Forms Current User: Not Logged In
Bedfordshire Hospitals
NHS Foundation Trust
A&E Documentation and Prescribing Practice Audit
MEDICAL
Code No:
Admission Date:
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Data collected by:
No. hours patient was in A&E:
DOCUMENTATION STANDARDS
Indicator 1
Q 1 How many pages in the casualty card have been used?
Indicator 2
How many additional entries were made on Extramed?
Q 2 How many entries have been made
in the casualty card during the care in A&E?
How many entries in the A&E card were legible in your opinion?
Indicator 3,4,5
How many are signed?
Q 3 How many entries are in dark ink?
How many of these entries are identifiable (i.e. printed name or log book)?
Indicator 6
How many of these are dated using the English
format (DDMMYY)?
Q 4 How many entries are dated?
How many of these are timed using the 24 hour
clock?
How many entries are timed?
Indicator 7
How many of these are scored with a single line,
dated and signed?
Q 5 How many times have there been alterations?
How many of the alterations have the correct
entry recorded alongside the original?
Indicator 8
How many of these are dated,
signed and timed?
Q 6 On how many occasions have entries been
added to?