Setting

This audit is relevant to all psychiatric specialties and can be adapted for outpatient reviews.

Background

Medical note-keeping is an important part of clinical practice. It provides a record of patient progress and continuity of care, a basis for communication within the multidisciplinary team, a record for coding and research, and is a medico-legal requirement. Guidance from the General Medical Council (GMC) (2006) states: ‘Keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decision made, the information given to the patients and any drugs or other treatment prescribed’. There are no specific guidelines for psychiatric records but in Good Psychiatric Practice (2009) the Royal College of Psychiatrists recommends that the GMC guidance is followed.

The Audit Commission's ‘payment by results’ (PbR) data assurance framework in 2008 found significant levels of error with medical coding. The most common factor contributing to errors was the quality of the source documentation from which the coding data were extracted. This included illegible or poorly structured case notes.

Standards

Following review of published standards and wide consultation, the Health Informatics Unit of the Royal College of Physicians (2009) produced generic medical record-keeping standards. Standard 6 requires that every entry in the medical record is dated, timed (in 24-hour format), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against the signature. Deletions and alterations should be countersigned, dated and timed.

Method

Data collection

Ten sets of patient notes in each in-patient unit were selected. The entries made on a specified date (a week or two earlier) were examined. Each medical entry should have been legible and was examined for the presence of:

ᐅ date and time

ᐅ a record of participants at the review

ᐅ signature, printed name and designation of the doctor making the entry

ᐅ where a particular plan had been documented, a further entry to establish that this was carried out (e.g. blood results where blood tests were planned).

Data analysis

The percentage of entries meeting the following standards was calculated:

ᐅ presence of a date and time

ᐅ list of participants at review

ᐅ presence of a signature, printed name and designation of doctor

ᐅ legibility of entries

ᐅ documentation of the completion of plans.