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Auditing psychiatric out-patient records


Purpose - Up-to-date patient records are essential for safe and professional practice. They are anrnintrinsic component for providing adequate care and ensuring appropriate and systematic treatmentrnplans. Furthermore, accurate and contemporaneous notes are essential for achieving professionalrnstandards from a medico-legal perspective. The study's main aim was to investigate currentrnrecord-keeping practices by looking at whether out-patient communication pathways to generalrnpractitioners, from letter dictation to insertion in the chart, were being satisfied.rnDesign/methodology/approach - From current out-patient attendees over six months, 100 chartsrnwere chosen randomly, and reviewed. A pro-forma was used to collect data and this information wasrnalso checked against electronic records.rnFindings - Of the charts reviewed, 15 per cent had no letter. If one considers that one-month is anrnacceptable time for letters to be inserted into the chart, then only 11 per cent satisfied this condition.rnElectronic data were also missing.rnResearch limitations/implications - It is impossible to discern whether letters to GPs wererndictated by the out-patient doctor for each patient reviewed. Another limitation was that somernmultidisciplinary hospital teams have different out-patient note-keeping procedures, which makesrnsome findings difficult to interpret.rnPractical implications - The review drew attention to current record-keeping discrepancies,rnhighlighting the need for medical record-keeping procedures and polices to be put in place. Alsornbrought to light was the importance of providing a workforce sufficient to meet the out-patient team'srnadministrative needs. An extended audit of other medical record-keeping aspects should be carried outrnto determine whether problems occur in other areas.rnOriginality/value - The study highlights the importance of establishing agreed policies andrnprocedures for out-patient record keeping and the need to have a checking mechanism to identifyrnsystem weaknesses.......

【作者名称】: Selena Pillay, Sarah O'Dwyer, Marguerite McCarthy
【关 键 词】: auditing, outpatients, quality standards, communication, Ireland
【期刊名称】: International journal of health care quality assurance
【期刊论文数据库】: [DBS_Articles_01]
【期刊论文编号】: 107,961,782
【摘要长度】: 2,034
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