Improving Standards in Psychiatric Case Notes Recording by Junior Doctors in an Inpatient Setting
Good standard of clinical record keeping and medical case notes are essential in ensuring high quality care of patients as well as aid communication between diffe-rent team members. It also informs medico legal inves-tigations, clinical audit as well as research.1 In psy-chiatric practice, good history, detailed mental state examination and risk assessment as well as relevant physical examination forms the basis for accurate dia-gnosis, formulation as well as management decisions.Faculty members as well as nursing staff observed the variability of case notes recording by psychiatry residents and how it impacts the patient care. The stu-dy described here comprises of an audit of case notes documentation on patients' admission in an inpatient setting and a subsequent re-audit following an educa-tional intervention. The overall aim of the audit was to examine the standard of recording certain key items of information and mental and physical examination in patients' case notes on admission. Absence of these items implied that these important aspects of patients care has not been considered or done. Therefore, the audit apart from assessing the standards of case notes recording indirectly also assessed the standards of patient care. No previous audit on this topic had been conducted in the department and we were unable to find record of any similar audit in search of Pakistani journals database.
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