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Improving documentation of physical health investigations in an adolescent mental health inpatient unit.

ABSTRACT: Physical health investigations, such as blood tests, ECGs, and appropriate radiological tests, are essential in the assessment and management of many patients in inpatient mental health settings. This project took place in a 12-bed adolescent mental health unit in Swindon, UK, where on average at least two-thirds of patients have a diagnosed eating disorder. Multidisciplinary ward rounds provide an appropriate setting for discussion and documentation of physical investigations. Over a two-week period, 22 electronic ward round entries were audited for any documentation of five common investigations - blood tests, ECG, MRI head, DEXA, and ovarian ultrasound. Blood tests were documented in 2/22 (9.1%), ECG, MRI head, DEXA, and ovarian ultrasound were documented in 0/22 (0%). Modifications were made to an electronic ward round template, to include headings for each of these investigations, with free-text boxes as well as drop-down boxes for the radiological tests. Following this, re-audit of 22 ward round entries over a two-week period showed documentation had hugely improved - blood tests were documented in 21/22 (95.5%), with ECG, MRI head, DEXA, and pelvis US all documented in 22/22 (100%). A further audit a month later showed these results were largely sustained. In conclusion, use of a simple, structured ward round template can hugely improve documentation of important physical investigations within mental health settings.

SUBMITTER: Horton D

PROVIDER: S-EPMC4693065 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Improving documentation of physical health investigations in an adolescent mental health inpatient unit.

Horton David D

BMJ quality improvement reports 20150819 1

Physical health investigations, such as blood tests, ECGs, and appropriate radiological tests, are essential in the assessment and management of many patients in inpatient mental health settings. This project took place in a 12-bed adolescent mental health unit in Swindon, UK, where on average at least two-thirds of patients have a diagnosed eating disorder. Multidisciplinary ward rounds provide an appropriate setting for discussion and documentation of physical investigations. Over a two-week p ...[more]

PMID: 26734411

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Project description:A frequently occurring job during on-call and out-of-hours shifts is reviewing a patient following a fall with this often being the responsibility of the most junior and inexperienced doctors. Following a pilot audit we identified inconsistencies in medical assessment and documentation, with 50% of expected data points not recorded. Failure to complete a thorough assessment can lead to missed injuries, prolonged length of stay, and litigation. Using the plan, do, study, act (PDSA) cycle model this project sought to address this through providing teaching to junior doctors and the development of a pro-forma. Three style cycles of data collection were performed; a formal baseline dataset, after delivering a teaching session to new junior doctors and following the trial of the new fall pro-forma. We selected 15 to 17 patient notes to review at random during a one month period for each data collection cycle and compared the medical assessment to the standards outlined by the National Patient Safety Agency (NPSA) guidelines.[1] There were two key areas of improvement identified following the teaching session and introduction of the proforma. Documentation of a fall history was improved by nearly 30% being recorded in 100% of cases after the interventions. Documentation of a thorough musculoskeletal examination was improved from being recorded in just 54% of cases to 77% of cases; it was recorded in 100% of the cases where the proforma was used. The project demonstrated the need to improve documentation and assessment of a patient who has fallen. Initial data collection has shown that assessment and documentation were improved providing teaching to junior doctors and by use of the document. The pro-forma has since been incorporated into hospital policy and now forms the compulsory documentation expected of the doctors and nurses managing patients following a fall. Ensuring easy access to the proforma and re-auditing after editing the document will be the next steps.

Project description:Physical health monitoring of patients receiving antipsychotics is vital. Overall it is estimated that individuals suffering with conditions like schizophrenia have a 20% shorter life expectancy than the average population, moreover antipsychotic use has been linked to a number of conditions including diabetes, obesity, and cardiovascular disease.[1-4] The severity of possible adverse effects to antipsychotics in adults has raised awareness of the importance of monitoring physical health in this population. However, there is little literature available as to the adverse effects of these medications in the child and adolescent community, which make physical health monitoring in this predominantly antipsychotic naïve population even more important. An expert group meeting in the UK has laid down recommendations in regards to screening and management of adult patients receiving antipsychotics, however no specific guidelines have been put in place for the child and adolescent age group.[5] The aim of this audit was to establish whether in-patients receiving antipsychotics had the following investigations pre-treatment and 12 weeks after treatment initiation: body mass index, hip-waist circumference, blood pressure, ECG, urea and electrolytes, full blood count, lipid profile, random glucose level, liver function test, and prolactin. This is in addition to a pre-treatment VTE risk assessment. These standards were derived from local trust guidelines, NICE guidelines on schizophrenia [6] and The Maudsley Prescribing Guidelines.[7] We retrospectively reviewed 39 electronic case notes in total, of which 24 cases were post intervention. Intervention included the use of a prompting tool. This tool was filed in the physical health files of all patients receiving antipsychotics which was intended as a reminder to doctors regarding their patient's need for physical health monitoring. Professionals involved in the monitoring of such parameters were educated in the importance and purpose of its use. Following this intervention re-audit occurred after 6 and 16 months of the initial audit to establish whether the use of the prompting tool caused any significant change in clinical practice. Overall performance in monitoring physical health parameters was initially poor, however we were able to demonstrate that with the help of a single prompt sheet there was a significant improvement following post intervention audit for the majority of parameters being monitored.

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Project description:BackgroundTherapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation.MethodsThe study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward.ResultsOnly 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models.ConclusionThese findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts.

Dataset Information

Improving documentation of physical health investigations in an adolescent mental health inpatient unit.

Publications

Improving documentation of physical health investigations in an adolescent mental health inpatient unit.

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