RESUMO
INTRODUCTION: 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. AIMS: 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. METHODOLOGY: Criteria based on GMC Good Medical practice guidelines (2013), RCPsych Good Psychiatric Practice (2009) and Records Management Policy. CONCLUSIONS: Good practice was maintained for most parameters. Mild inaccuracies were noted with date of birth/ward name, timing and signatures. RECOMMENDATIONS: 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.
