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35 - Physical health of in-patients: record-keeping

from III - Physical health

Published online by Cambridge University Press:  02 January 2018

Neel Halder
Affiliation:
Greater Manchester West Mental Health NHS Foundation Trust
Shoba Salanki
Affiliation:
Calderstones NHS Foundation Trust
Clare Oakley
Affiliation:
Institute of Psychiatry, King's College London
Floriana Coccia
Affiliation:
University of Birmingham
Neil Masson
Affiliation:
NHS Greater Glasgow and Clyde
Iain McKinnon
Affiliation:
National Institute for Health Research, Newcastle University
Meinou Simmons
Affiliation:
Cambridge and Peterborough Foundation Trust
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Summary

Setting

This audit was conducted in an in-patient intellectual disability service but is relevant to all psychiatrists working with in-patients.

Background

A comprehensive, systematic investigation of physical health is a core component of the psychiatric assessment. If a patient's stay at an assessment and treatment facility becomes prolonged, it is essential that psychiatrists recognise the need for active health promotion, including formal health checks. This is particularly important in the continuing healthcare setting, where psychiatric services, in effect, assume the role normally carried out by the primary care team.

Standards

Standards were obtained from the Royal College of Psychiatrists’ 2009 report Physical Health in Mental Health. Of particular relevance were:

ᐅ physical examination of the patient within 24 hours of admission should be recorded in the patient's medical record (where this cannot be done, there should be a clear entry in the notes with an appropriate explanation)

ᐅ a record of health promotion/screening (e.g. smoking cessation) should be in the patient's notes

ᐅ medical history should be obtained within 1 week and made available in the patient's notes

ᐅ for those with epilepsy, a record of information concerning seizure type, frequency and rescue medication should be obtained within 1 week of admission and made available in the patient's notes

ᐅ weight and blood pressure should be recorded monthly.

Method

Data collection

Information pertaining to all of the above standards should be documented in the patients’ medical records. An anonymous pro forma was designed, with a simple checklist corresponding to the above standards.

Data analysis

The proportion of patient records in compliance with the standards was calculated.

Resources required

People

This audit was undertaken by one person. For more than 25 patients, it is advisable that at least two people are involved. It is suitable for multidisciplinary involvement.

Time

Approximately 30 minutes per set of case notes was required. The time taken will depend on the quality of note-keeping and ease of finding the information.

Results

ᐅ Most patients received a physical examination by a doctor within 24 hours of admission. However, when this was not possible (perhaps because of the patient's extreme agitation), the reason was not adequately documented.

ᐅ For patients with epilepsy, there was reasonable recording in the notes of seizure type and frequency, but not of rescue medication.

ᐅ The recording of weight was erratic.

Type
Chapter
Information
Publisher: Royal College of Psychiatrists
Print publication year: 2011

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