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Improvements in practice from assessing standards of recording psychiatric case-notes

  • Tom O'Hare (a1)
Abstract

The case-notes of all patients in a district general adult psychiatric unit were assessed for standards of recording selected key items. The results were presented at a departmental audit meeting, and the assessment repeated after four months. Initial audit revealed poor standards of notekeeping in certain areas. On repeat assessment, standards of documentation had improved for all the key items assessed, and reached statistical significance for physical examination. This audit was quick, easy and cheap, revealed unexpectedly poor standards of notekeeping, and evidently produced a measurable and significant improvement in practice.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Improvements in practice from assessing standards of recording psychiatric case-notes

  • Tom O'Hare (a1)
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