Inpatient Ward Review Documentation Audit

Abstract

Aims

Good medical records are essential to the continuity of patient care. The aims of this audit were to evaluate the quality of ward review documentation in 7 Psychiatry wards in Essex Partnership University NHS Foundation Trust, to identify areas of improvement, to recommend strategies to improve record keeping, and to measure their effectiveness by comparing records in the 1st and 2nd cycles of audit.

Methods

A sample of 10 patients from each of the 7 wards was selected, for a total of 70 patients, in each of the 1st and 2nd cycles of the audit (Data were collected in the 1st cycle between 06-07-2021 and 22-07-2021, and 2nd cycle between 16-10-2022 and 07-11-2022). Samples were selected randomly among patients who were inpatient or discharged recently. The data were collected from the first, middle, and last ward reviews. If the patient was inpatient at the time of the data collection, data were collected from their first review, the last/most recent ward review, and one of the reviews in between. Patients who did not meet this criterion were excluded. Based on 1st cycle results, strategies were recommended to improve record keeping. After 15 months, 2nd cycle results were used to evaluate their effectiveness.

Results

The results demonstrate significant areas of improvements in record keeping: a majority of questions did not meet the standard of 80% completion considered “satisfactory” in previous audits. In the 2nd cycle, 9 questions had a “satisfactory” completion rates. These were mandatory or automated questions and ones essential to immediate patient care. 7 questions had “average” completion rates above 45%. All (17) other questions and subquestions had “low” completion rates. Analysis of variations between cycles shows that question on “Responsible clinician” increased from 23.3% to 99.5% because it was automated. 4 other questions or sub-questions have seen a substantial increase in completion rate between the 1st and 2nd cycle. But our strategies’ effectiveness during the period of the audit has proven limited and difficult to trace.

Conclusion

It can be concluded that more efforts should be dedicated to improving medical record in the psychiatry wards of Essex Partnership University NHS Foundation Trust. The most effective strategy to secure high ward review docummentation rates remains to make questions mandatory or auto-complete when possible. More research is necessary to demonstrate the effectiveness of other strategies such as the education of junior doctors in induction and awareness posters in wards.