This clinical audit is aimed at assessing the knowledge, attitude and practices of team members towards compliance regarding information sharing and consenting service users and to create awareness about existing Trust policies and national guidelines, importance of gaining consent for Information Sharing. Consent to share information should be recorded on the appropriate clinical record keeping system and/or paper. Service users also have the right to request that information is not shared – and staff must record these decisions in the clinical record. Team members work with other agencies and at times need to share patient information. Hence, there should be discussion about who information is going to be shared with, and why. A recorded consent is useful in instances when patient data may need to be shared in court.

The 1st cycle of the audit was conducted from 15th of December 2022 to 4th of January 2023. Clients that met the inclusion criteria were checked to see if the form was filled in by the relevant practitioner/ ever filled in. This was done for both the Community Mental Health Team (CMHT) and Memory assessment Services (MAS). A survey with 7 questions was sent out to team members to assess their knowledge of the Trust policy as well as national guidelines on consent on information sharing.

A total of 238 service user records were assessed. 119 each under CMHT and MAS. Combined results of 37% of the 238 services users had consent documented while 63% did not have consent documented. 27% of services users under MAS had consent obtained and documented. 56% of service users under CMHT had consent obtained. 100% of team members that responded to the survey knew to discuss personal and confidential information sharing with patients. 91% of staff knew that the discussion on consent and information sharing should be documented. 23.5% of staff were not aware of trainings on information sharing and 35.3% of staff were unaware of where to document the consent.

Although rare, unrecorded discussion/consent on Information sharing can cause serious implications. This audit highlights the need to create awareness about the importance of recording Information Sharing consent. Possible reasons for results include team members not being aware of where to document in client records, Trust has not properly educated staff on Information sharing and the way to record it in electronic health records and the Concept of implied consent.