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

Abstract

This 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.