• Med Sci Law · Apr 2008

    An audit of basic record keeping standards: lessons learnt from the Royal College of Physicians.

    • Nuwan Galappathie, Krishma Jethwa, and Biljana Andonovska.
    • Fromeside Clinic, Blackberry Hill, Bristol. ngalappathie@doctors.org.uk
    • Med Sci Law. 2008 Apr 1; 48 (2): 155-8.

    AbstractThis paper describes an audit of the basic standard of record keeping for inpatient clinical records. Following an initial audit, the Royal College of Physicians' inpatient record keeping standards 6 and 7 were adopted. The standard was then reassessed in a second audit. During the first audit, 189 medical entries were assessed and 274 were assessed on repeat audit. A significant improvement was achieved in many areas including recording of time (19-82%), name of author (60-89%), location of patient (58-94%) and identity of the most senior doctor present (68-89%), (p<0.001). The Royal College of Physicians' record keeping standards through the use of audit can lead to considerable improvement in the standard of record keeping within psychiatric practice.

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