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Advances in Psychiatric Treatment (2006) 12: 280-286
© 2006 The Royal College of Psychiatrists

Improving standards in clinical record-keeping

Ian Pullen and John Loudon

Ian Pullen has recently retired from the NHS where he was Principal Medical Officer at the Scottish Executive Health Department, Edinburgh, UK (email: ipullen{at}doctors.net.uk). John Loudon, a retired consultant psychiatrist, is Mental Health Adviser to NHS Quality Improvement Scotland, which has recently developed a Mental Health Quality Improvement Strategy. He was chair of the Clinical and Resource Audit Group’s Case Records Good Practice Team.

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen’s reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.




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