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Table 1 Audited items

From: A prospective evaluation of inter-rater agreement of routine medical records audits at a large general hospital in São Paulo, Brazil

Audited items Rating Options
Secondary diagnosis Adequate or inadequate
Chief complaint Not applicable, adequate or inadequate
History of presenting complaint Not applicable, adequate or inadequate
Past medical history Not applicable, adequate or inadequate
Medication history Not applicable, adequate or inadequate
Complete medical history Not applicable, adequate, inadequate or incomplete
Physical exam Adequate or inadequate
Diagnostic testing Not applicable, adequate or inadequate