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Table 1 List of clinical forms and sections to be assessed in the intervention

From: Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project

Name of the medical form Name of the section on the medical form List of the fields
Hospital registration card (Green card) Patient details section Patient ID, name, DOB, age, sex, date of registration, time of registration, occupation, tribe, religion, place of birth, current address, patient phone number, next of kin name, and phone number
Triage section Date, time, and nurse name or signature
Patient clerking and compulsory clinical documentation sections Date, time, grade, name of doctor, contact of doctor, signature of doctor
Surgical admission folder (yellow folder) Cover page Consultant name, patient ID, name, DOB, age, sex, date of registration, tribe, religion, place of birth, current address, patient phone number, next of kin name and phone number
SLEWS One entry for each shift Date, time, name, and signature of designated person, all 6 vital signs (respiratory rate (RR), oxygen level (%), temperature, blood pressure (BP), pulse, alert-verbal-pain-unresponsive (AVPU) level, SLEWS score, and the time and name of doctor that has been called
Nurses daily report  Compulsory heading fields on each page Patient ID, DOB/age, sex, name
Application of Nursing Documentation Framework (a new framework to be introduced by this project), to be completed on each shift Date, time, signature, and name of designated person; quality note recording under a set of agreed headings (to be determined)