Documentation and Record Keeping Flashcards

A patient refuses to sign their CPA care plan. What is the recommended documentation practice?

Answer: Document the refusal and the reasons given, and proceed with the plan

The refusal and the patient's stated reasons should be documented clearly; the care plan can still be implemented and the refusal does not invalidate it.

Which RCPsych guidance addresses standards for record keeping in child and adolescent psychiatric services specifically?

Answer: CR182

CR182 (Good Psychiatric Practice: Confidentiality and Information Sharing) and supplementary CAMHS standards guide documentation in child and adolescent services.

An SHO documents a suicide risk assessment but omits the protective factors identified. Why is documenting protective factors clinically and legally important?

Answer: They demonstrate a balanced assessment and support defensible clinical decision-making

Recording protective factors demonstrates a balanced, thorough risk formulation and is essential for defensible practice and safe discharge planning.

Under the NHS Records Management Code of Practice, what is the minimum retention period for adult mental health records?

Answer: 20 years from last contact or 10 years from death

The NHS Records Management Code of Practice specifies retention of adult mental health records for 20 years from last contact or 10 years from death, whichever is longer.

A consultant psychiatrist discovers that a trainee has back-dated a clinical entry to cover a delay in documentation. What is the most appropriate first step?

Answer: Discuss with the trainee and ensure the entry is corrected with the actual date and time noted

The entry must be corrected to reflect the actual date of documentation; this should be discussed with the trainee as a teaching and governance matter.

Which coding system is most commonly used in UK NHS psychiatric record systems for diagnostic documentation?

Answer: ICD-10 codes

ICD-10 codes are the standard diagnostic coding system mandated for NHS clinical records and commissioning data in the UK.

A patient is admitted informally but later objects to continued admission. What documentation must be completed before any change in legal status?

Answer: A written record that the patient has been informed of their right to leave and a capacity assessment

When an informal patient objects, documentation must record that the patient was informed of their right to leave and a capacity assessment should be completed to guide further legal steps.