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Improvements in practice from assessing standards of recording psychiatric case-notes

Published online by Cambridge University Press:  02 January 2018

Tom O'Hare*
Affiliation:
Edenfield Centre, Mental Health Services, Bury New Road, Prestwich, Manchester M25 3BL
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Abstract

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The case-notes of all patients in a district general adult psychiatric unit were assessed for standards of recording selected key items. The results were presented at a departmental audit meeting, and the assessment repeated after four months. Initial audit revealed poor standards of notekeeping in certain areas. On repeat assessment, standards of documentation had improved for all the key items assessed, and reached statistical significance for physical examination. This audit was quick, easy and cheap, revealed unexpectedly poor standards of notekeeping, and evidently produced a measurable and significant improvement in practice.

Type
Audit
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 1995
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