Abstract
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.
Highlights
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
Standards of documentation had improved for all the key items assessed, and reached statistical significance for physical examination
Summary
On 30 March 1994, a survey was made of the medical case-notes of all in-patients in the three wards of a district general hospital adult psychiatric unit. Records for the current admission were scrutinised with reference to documentation of mental state, physical examination, diagnosis, and management plan. Well kept medical case-notes are crucial in ensuring high quality care, as well as being an important source of medico-legal information. The purpose of this audit was to examine the sintafnodrmaradtionofinreinc-opradtiinegnts'cecrtaasien-nokteesy. IAtebmsesncoef of these items implies that procedures may not have been carried out, or that important aspects of patient management have not been considered. In addition to measuring directly the standard of record keeping, this audit gave an indirect measure of standards of patient care
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