Medical Record Documentation in a Learning Disability In-patient Unit

Consistency in clinical structure and content is an important aspect of clinical practice. The rising demands on healthcare systems and associated costs require a much more efficient and transparent means of recording and accessing reliable clinical information in order to manage and deliver good quality care to patients.

The audit has been completed with an aim to highlight the local standards set for medical record documentation and to assess if the outlined standards are being met in a learning disability in-patient psychiatric setting, the Coppice.

Criteria based on GMC Good Medical practice guidelines (2013), RCPsych Good Psychiatric Practice (2009) and Records Management Policy.

Good practice was maintained for most parameters. Mild inaccuracies were noted with date of birth/ward name, timing and signatures.

This was presented locally and measures put in place to address the gaps. A re-audit should be performed within a year in order to complete the audit cycle and to ensure that the recommendations and action plan have been followed through.