Assessing Whether Physical Health Forms Are Completed for Every New Admission on a Mental Health Ward

Abstract

Aims

The audit assessed whether physical health forms, which are separate from admission clerking notes, were being completed for new admissions on the ward. A physical exam has to be carried out for every new admission and the findings recorded on the form within 24 hours of the admission. After the first audit cycle, recommendations were to be made and interventions carried out. A re-audit was completed to assess the compliance.

Methods

The records of all patients admitted onto a ward at a mental health unit on the 1st of October 2022 were reviewed to determine whether the admitting doctors had completed the physical health form or not. This was recorded on an excel sheet as complete, recorded on clerking but form not complete, or patient was not seen. After data extraction, junior doctors were reminded about the form personally and a poster was made informing junior doctors about the form which was placed in the junior doctor's room. A re-audit was carried out four months later.

Results

The audit showed that the forms for 75% of patients were not completed by the duty doctor on admission. Out of the forms that were not completed, one patient was not clerked in on time and one patient did not want to see the doctor and refused examination. Therefore, 65% of patients were examined and examination recorded on admission clerking, but the form was not completed. On the second cycle, 35% of the forms were not completed with one patient refusing examination, thus, 30% of the forms were not completed despite examination being carried out.

Conclusion

The recommendations and interventions proved to be successful as the compliance in completed forms increased. Further interventions such as frequent reminders and mentioning the importance of the form on induction could be made. A third cycle to assess compliance among the new junior doctors rotating onto the unit could be completed to assess the effectiveness of these interventions.