Improving documentation of side-effects discussions by doctors for newly initiated psychotropic medications in outpatient clinics: A single-centre quality-improvement project

Abstract

Background: Robust clinical documentation of side-effects communication is an integral component of good patient care, endorsed by the Singapore Medical Council Ethical Code and Ethical Guidelines and further highlighted by the Modified Montgomery Test. In addition to ensuring quality of care, good clinical documentation can help mitigate potential medico-legal risks against doctors and health-care providers. Objectives: This audit-cum-quality-improvement project aimed to enhance clinical documentation of side-effects discussion of newly prescribed medication in psychiatry outpatient clinics to 100% in a 12-month period. Methods: A baseline measurement revealed that 40% of new cases seen in general and geriatric psychiatry outpatient clinics from March to June 2017 had evidenced clinical documentation of at least one or more side effects. PDSA methodology was employed to bring about improvements and test change interventions. Results: Through three audit cycles between January and December 2018 and a fourth round of data collection in April 2019, documentation rates showed marked improvement from a baseline of 40% to 91%. The IT document tool was the most effective intervention which was successfully adopted and implemented into the standard documentation template for new case assessments. Conclusions: The project was a success overall, with improvements in documentation rates rising to 91%. Through change interventions, systemic factors rooted in patient safety have been embodied in everyday clinical practice.