Psychiatric admission booking: audit of the impact of a standardised admission form

AIMS AND METHOD

We used a complete audit cycle to assess the quality and completenessof current admission bookings by junior doctors and whetherthe introduction of a standardised admission form led to improvements.

RESULTS

Following the introduction of the standardised form significant improvements were found in almost all areas, including therecording of basic data, history, mental state, physical examination,risk assessments and diagnosis.

CLINICAL IMPLICATIONS

The introduction of a standardised admission form improved thecompleteness of information obtained. The form may also beused as an educational tool and to assist trainees preparingfor examinations.

Introduction

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Introduction

The information obtained at the time of admission is importantfor the care of some of our most ill patients and informs allareas of assessment, diagnosis and the care planning process,including risk management strategies. The quality and completenessof the recorded information has a direct impact on the qualityof patient care. Such a central document also clearly has medicolegalimplications if incomplete or incorrect. This has been previously demonstrated in the documentation of risk (Elbogen et al, 2003), but is also relevant to other aspects of assessment, as wellas the general documentation of patient care (Scott, 2000).

In our trust the current method of using hospital continuationsheets for admissions had led to concerns over the comprehensivenessof the information obtained, and the impact on the qualityof in-patient care and medico-legal implications. Althoughthe quality of the admission booking depends on the doctor’slevel of training and experience, their attitude and enthusiasm and the patient’s cooperation, it is clearly stated thatcompetent note-keeping is a core component of good psychiatricpractice in the College’s council report of the samename (Royal College of Psychiatrists, 2004).

Previous studies have demonstrated that significant data areoften omitted from psychiatric case notes (Small & Fawzy, 1988)and that the introduction of standardised formats for mentalstate examinations improves the quality of the information obtained (Kareem & Ashby, 2000). It has also been suggested thatstructured assessment schedules may assist trainees in statingthe likely diagnosis, investigation and management at the timeof admission (Lyons et al, 2001). This audit was thereforedesigned to address the question of what impact the introductionof a standardised form has on the overall completeness of informationobtained at admission booking.

Method

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Method

A list of standard information was developed by combining recommendations from multiple sources, including trust policy documents andCollege guidance on history-taking and mental state examination.Standards were set for 100% of admission forms to have thepatient’s basic data, mental state examination, physicalexamination, clinical risk assessment, diagnosis and managementdocumented. A standard of 80% was set for each of the componentsof the patient’s history to reflect some inevitable slippageand to allow discretion to be applied by the admitting doctor.It was deemed acceptable if booking forms referred to previousspecific entries where information could be found or gave aclear reason for omitting information (e.g. uncooperative patientrefusing physical examination).

Case notes of 30 current in-patients were then assessed forcompleteness. This represented 80% of the average number ofin-patients on the wards and was considered to be a representativesample enabling repeat sampling to be performed to completethe audit cycle. Adolescents and patients admitted by the substancemisuse specialist team were excluded as they would require differinghistories, focusing on the specialist requirements of those services. Two authors (J.D. and M.C.) assessed the notes andwhere uncertainty occurred consensus agreement was used toimprove interrater reliability. The presence of some informationor a valid reason explaining its omission was accepted. Thequality of the information documented was not assessed as this was felt to decrease the objectivity of the assessment.

A standardised core assessment form was then developed by incorporatingall aspects of basic data, history, mental state examination,physical examination, a summary of findings, a clinical riskassessment, diagnosis and management plan in collaborationwith trainees and the consultant body. Trainees were consideredto be the most likely doctors to use the form and were surveyedfor their opinions in order to help increase their sense of ownership of the form. A training session in the use of theform accompanied its introduction. A further sample of casenotes from 30 patients was similarly assessed 3 months followingthe form’s introduction.

Statistical analysis was performed using the Statistical Packagefor the Social Sciences version 11.5 for Windows. Pearson’s ${chi}$ ² test was performed to assess the statistical significanceof changes (P $≤$ 0.05) in the completeness of the information obtainedat the time of admission.

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Fig. 1. Completeness of information obtained at the time of admission before and after the introduction of the standard form. ##, Before form; ${blacksquare}$ , after form.

Results

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Results

Prior to the introduction of the form, there were low levelsof recording of family and personal history, premorbid personality(n=4, 13%), clinical risk assessment (n=5, 17%) and diagnosis (n=12,40%), as wellas doctor’s name and signature (n=9,30%). Furthermore, a physical examination (or clear reason for its omission) was documented in only 17 case notes (57%). Allof these areas showed significant improvement following theintroduction of the standard form (Table 1, Fig. 1). Improvementsin the recording of physical examination (P=0.002), a summaryof findings (P=0.004), risk assessment (P<0.001) and diagnosis (P=0.001) were all statistically significant. Small, statistically insignificant, drops in the recording of source of referraland history of presenting complaint were noted, which probablyreflect the high levels of completeness of these data priorto the form’s introduction. A larger drop was noted inthe completion of the management plan, but again this did notreach statistical significance (P=0.222). Reasons for this are discussed below.

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Table 1. Audit of admission booking before and after introduction of the standard form: history (n=30 for both)

Discussion

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Discussion

This audit demonstrates that significant improvement in thecompleteness of almost all information obtained at the timeof patient admission can be achieved by the introduction ofa structured, standardised admission form. A drop in the recordingof a management plan was noted following the introduction ofthis form. This may be because the form required the plan to take a biopsychosocial approach to reflect the requirementsof trainees sitting the College examinations and in accordancewith College recommendations for good psychiatric practice (Royal College of Psychiatrists, 2004). This may have discouragedtrainees who did not feel competent to complete all areas ofthe plan. This requires further exploration and possible educationto address the issue. Furthermore, none of the original standardswas fully met and this indicates the need for further trainingand supervision for trainees admitting acute patients.

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Table 2. Audit of admission booking before and after introduction of the standard form: mental state examination (n=30 for both)

Overall the form was considered acceptable, as demonstratedby the high level of use and subsequent meetings to furtherrefine the form. It is felt that this resulted primarily fromthe active involvement of the trainees in its development.It has subsequently also been adopted as an educational tool in teaching sessions. It was felt that the improved completionof assessments as a result of use of the standard form outweighedany disadvantages such as reduced autonomy and discretion ofthe clinician, or the possible sense of complacency that canbe induced by forms that merely require boxes to be ticked.

As an audit the study does have limitations. There is a subjective component to the assessment of the information and possiblevariability between assessors might introduce bias. Frequentconsultation between the assessors was used to limit this.Assessors were not masked as to whether the information wasobtained prior to or following the introduction of the form, which may further bias their assessment of its completeness.Furthermore, it is also possible that some of the improvementin the completeness of the information occurred because ofthe increased profile resulting from the audit process itself(O’Hare, 1995). Finally, the audit does not assess accuracyor other aspects of the quality of the recordings. This hasbeen highlighted previously as a shortcoming of using auditto assess the quality of patient documentation (Blakey, 2000).

Overall, this audit emphasises the vital role admission bookingplays in the provision of quality care to patients admittedto psychiatric units. Those doctors involved in admitting patientsmust receive adequate training and supervision to ensure comprehensiveinformation is obtained. This audit suggests that the introductionof a standardised admission form may assist in improving thequality of such information.

References

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