Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle.

Abstract

This paper summarizes a novel quality improvement initiative by a Child and Adolescent Psychiatry outpatient service to enhance the quality of clinical documentation through effective use of a standardized template. It involved carrying out an initial audit, implementation of an action plan to rectify the identified shortcomings, and completion of the audit cycle by repeating the process a year later. A significant improvement was noted across all the measurable standards. We have demonstrated that standardization of clinical documentation, reviewing and addressing factors affecting the compliance rates, and providing necessary training to doctors can all enhance the quality of clinical documentation.