Conference paper

MEDICAL RECORD DOCUMENTATION IN A LEARNING DISABILITY IN-PATIENT UNIT

Madhusudan Deepak Thalitaya ; East London NHS Foundation Trust, London, UK ; Twinwoods Medical Centre, Clapham, Bedfordshire, Bedford, UK
Sujanita Thyagarajan ; South Essex Partnership University NHS Foundation Trust, UK
Vaishali Tirumalaraju ; South Essex Partnership University NHS Foundation Trust, UK
Emil Mihaylov ; South Essex Partnership University NHS Foundation Trust, UK
Marina Mihaylova ; South Essex Partnership University NHS Foundation Trust, UK

Abstract

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.

Keywords

medical documentation

Hrčak ID:

264593

URI

https://hrcak.srce.hr/264593

Publication date:

8.9.2015.

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