An audit of psychiatric case notes in relation to antipsychotic medication and information giving

Bowler, Nic; Moss, Susanna; Winston, Mark; Coleman, Mick

doi:10.1108/14664100010361773

Cited by 3 publications

(2 citation statements)

References 24 publications

(14 reference statements)

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“…This information provision has been found to improve concordance with treatment (Chaplin & Kent 1998). Good record keeping and adhering to documentation standards is seen as essential for safe service users' outcomes and supports good nursing practice (Bowler et al . 2000).…”

Section: Introductionmentioning

confidence: 99%

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Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service

Cleary¹,

Walsh²,

Connolly³

et al. 2011

Psychiatric Ment Health Nurs

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Accessible summary The aim of this audit was to review current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. While many aspects of the audit highlighted deficiencies in the monitoring and recording of side effects of depot antipsychotic medication, some other areas of practice revealed encouraging results. The audit highlighted the need for improved clinical documentation and the need for a consistent approach to the assessment of side effects and movement disorders using valid and reliable assessment scales and the need for adequate information for service users and their carers. The need to gain service users' consent has also been highlighted. However, the audit did not address consumer insight into their illness which would impact on the giving of consent and adherence to medication and is worthy of exploration in future audit. In addition, the gap in prescribing and medical reviews requires addressing. A recommendation from the audit is the need to introduce simple checklists. The Glasgow Antipsychotic Side Effects Scale, which takes only 5 min to complete and is available freely in the public domain for use, has been chosen for adoption in the service area. Another simple scale, the Simpson Angus Scale, will also be introduced to assess movement disorders. Collaborative practice with feedback from service users is essential in service improvement and care delivery. This approach will be formally incorporated into future care delivery in the service area. Abstract This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

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Section: Introductionmentioning

confidence: 99%

“…2000). However, an audit of psychiatric case notes in relation to antipsychotic medication and information giving in the UK found lack of provision of such information in over half of the case notes audited, and where information was provided it was on an ad hoc basis (Bowler et al . 2000).…”

Section: Introductionmentioning

confidence: 99%