A key element of good in-patient psychiatric care is the multidisciplinary review, with accurate and legible recording of the outcome of the discussion. Traditionally, the junior doctor and nurse act as ‘scribes' on the ward rounds, recording the outcomes in the multidisciplinary or separate medical and nursing notes. There are a number of ways in which this process can fail. First, the scribe may simply misunderstand the decision of the team, given the complexity and variety of decisions in a psychiatric setting. Second, the scribe may understand what to record, but what is written may be illegible. Finally, people present at the ward round can have different beliefs about what has been decided, but unless they immediately review what has been written, they may not realise the discrepancy. One or more of these failings can result in serious untoward incidents, such as a patient being allowed off the ward on unescorted leave when the responsible medical officer believed the team had decided against permitting such leave. It is only when there is a serious incident that discrepancies can and do emerge.
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