To investigate the recording of Mental State Examination (MSE) findings by psychiatric trainees as well as dating, timing and signing of entries into the clinical record. Data were collected from randomly selected case notes in three acute psychiatric units.
There was an initial decline of MSE recording from 69% to 58% in the first re-audit. Introduction of a standardised format and involvement of consultant trainers in the supervision of MSE recording led to an improvement to 83% in the secondre-audit. Adherence to medico-legal standards also improved.
The introduction of an MSE format and consultant supervision of records improved the standard of MSE recording as well as basic medico-legal requirements by psychiatric trainees.
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