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Table 3 Overview of statement presence in each of the six data sources

From: A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients’ medical records

Data source

No. of statements judged explicit (% of total possible statements)

No. of statements judged implicit (% of total possible statements)

Total/possible (% of total possible statements)

1. Accident & Emergency (A&E) Triage form

88 (37%)

23 (10%)

111/236 (47%)

2. A&E Clerking form

146 (63%)

21 (9%)

167/232 (72%)

3. Post-take ward round form

144 (50%)

34 (12%)

178/228 (78%)

4. Handwritten case notes at 3 pm

95 (42%)

17 (7%)

112/228 (49%)

5. Handwritten case notes at transfer

32 (28%)

8 (7%)

40/116 (35%)

6. Electronic Discharge Communication

200 (75%)

47 (18%)

247/267 (93%)

Total

705

150

855/1307 (65%)