Academic Unit for Mental Health and Wellbeing, Centre for Population and Health Sciences College of Medical, Veterinary and Life Sciences University of Glasgow-Mental Health and Wellbeing, Glasgow, UK.
J Ment Health. 2011 Oct;20(5):438-44. doi: 10.3109/09638237.2011.577117. Epub 2011 Jul 22.
The quality of admission clerking to psychiatry wards will influence initial management of patients suffering from mental illness. Incomplete clerking may put patient safety at risk.
We sought to assess the completeness of clerking to general adult psychiatry wards and to evaluate whether the introduction of an admission booklet would improve clerking.
We analysed the completeness of clerking to general adult psychiatric wards by trainee doctors. Using an audit approach, the first phase assessed completeness of clerking when trainee doctors used continuation sheets to document the clerking in a free-hand manner. Thereafter, we developed a standardised admission booklet to document the clerking and assessed completeness of clerking in the second phase.
The admission booklet significantly improved the completeness of clerking. Notable improvements were seen in multiple components of history taking and initial management, particularly in documenting risk to self and others.
Improving clerking by use of an admission booklet can lead to more informed management decisions particularly in regard to the patients' physical health and clinical risk management. This may consequently improve patient safety and help trainees communicate important aspects of the case to seniors and the wider multi-disciplinary team.
入院记录员对精神科病房的工作质量将影响到精神疾病患者的初始治疗。记录不完整可能会使患者安全面临风险。
我们旨在评估普通成人精神科病房入院记录的完整性，并评估入院手册的引入是否能提高记录的完整性。
我们通过实习医生分析普通成人精神科病房入院记录的完整性。采用审核方法，第一阶段评估了实习医生使用续页以自由手写方式记录入院记录时的完整性。此后，我们开发了标准化的入院手册来记录入院记录，并在第二阶段评估了入院记录的完整性。
入院手册显著提高了入院记录的完整性。在病史采集和初始管理的多个方面都有显著改善，特别是在记录对自身和他人的风险方面。
使用入院手册来提高入院记录的完整性，可以做出更明智的管理决策，特别是在患者的身体健康和临床风险管理方面。这可能会提高患者的安全性，并帮助实习医生向上级和更广泛的多学科团队传达病例的重要方面。
