Abstract
ObjectivesMedical records are critical to patient care, but often contain incomplete information. In UK hospitals, record-keeping is traditionally undertaken by junior doctors, who are increasingly completing early-career placements in psychiatry, but negative attitudes towards psychiatry may affect their performance. Little is known about the accuracy of medical records in psychiatry in general. This study aimed to evaluate the accuracy of Electronic Medical Records (EMRs) pertinent to clinical decision-making (“rationale”) for prescribing completed by junior doctors during a psychiatry placement, focusing on the differences between psychotropic vs. non-psychotropic drugs and the temporal association during their placement.ResultsEMRs of 276 participants yielding 780 ward round entries were analysed, 100% of which were completed by Foundation Year or General Practice specialty training junior doctors rather than more senior clinicians. Compared with non-psychotropic drugs, documentation of prescribing rationale for psychotropic drugs was less likely (OR = 0.24, 95% CI 0.16–0.36, p < 0.001). The rate of rationale documentation significantly declined over time especially for psychotropic drugs (p < 0.001). Prescribing documentation of non-psychotropic drugs for people with mental illness is paradoxically more accurate than that of psychotropic drugs. Early-career junior doctors are therefore increasingly shaping EMRs of people receiving psychiatric care.
Highlights
Accurate medical record-keeping is of crucial importance for patient safety and quality of care [1, 2]
electronic medical records (EMRs) of 276 participants yielding 780 ward round entries were analysed, 100% of which were completed by Foundation Year or General Practice specialty training junior doctors rather than more senior clinicians
While traditional paper-based records are being fast replaced by electronic medical records (EMRs), allowing easier completion and retrieval of documentation, medical records in any format have been associated with limited accuracy, predisposing to negative repercussions on patient care [1]
Summary
Accurate medical record-keeping is of crucial importance for patient safety and quality of care [1, 2]. 2005, a redesigned programme of post-graduate training was introduced, permitting junior doctors in their initial two “Foundation Years” (FY) or those conducting general practice specialty training (GPST) to undertake successive 4-month posts in various medical specialties, including psychiatry [7, 8]. These doctors work alongside other doctors undertaking specialty training as their career choice. A proportion of junior doctors precipitate in psychiatry placements less enthusiastically than others, which may negatively influence their performance, including that related to record-keeping.
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