Medical Record Documentation in a Learning Disability In-patient Unit.

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.

Pro Re Nata (PRN) prescription in an Inpatient Low Secure Learning Disability Unit.

INTRODUCTION: Pro Re Nata (PRN) prescribing in psychiatry is a common and valuable facility to be used in acutely distressed patients. It is open to misuse and PRN prescribing may be unnecessary/inappropriate. AIM: The aim of the audit is to ensure safe and effective prescription of PRN medication. AUDIT STANDARDS: The standards were set in congruence with the guidance from the local trust policy. METHODOLOGY: All of the inpatient records at Wood Lea clinic were studied over a 2 month period. CONCLUSIONS: Most of the standards against which the clinical notes were assessed gave evidence of good medical practice. Patient demographics demonstrated a 100% record of the NHS number but the patient's name and ward fell short. RECOMMENDATIONS: This was presented locally and measures put in place to address gaps. Re-audit should be performed within a year in order to complete the audit cycle and to ensure that recommendations/action plan have been followed through.