MRCPsych Documentation and Record Keeping 3 — Questions and Answers
Question 1: A patient refuses to sign their CPA care plan. What is the recommended documentation practice?
- Delay implementation of the care plan until consent is obtained
- Document the refusal and the reasons given, and proceed with the plan (Correct answer)
- Obtain a court order before proceeding
- Complete a Mental Health Act assessment immediately
Correct 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.
Question 2: Which RCPsych guidance addresses standards for record keeping in child and adolescent psychiatric services specifically?
- CR166
- CR182 (Correct answer)
- CR216
- CR100
Correct answer: CR182
CR182 (Good Psychiatric Practice: Confidentiality and Information Sharing) and supplementary CAMHS standards guide documentation in child and adolescent services.
Question 3: An SHO documents a suicide risk assessment but omits the protective factors identified. Why is documenting protective factors clinically and legally important?
- Protective factors are irrelevant to risk; only risk factors matter legally
- They demonstrate a balanced assessment and support defensible clinical decision-making (Correct answer)
- They are only required if the patient is being discharged
- Documentation of protective factors is optional under NICE guidelines
Correct 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.
Question 4: Under the NHS Records Management Code of Practice, what is the minimum retention period for adult mental health records?
- 7 years from last contact
- 8 years from last contact
- 20 years from last contact or 10 years from death (Correct answer)
- Indefinitely, as no destruction is permitted
Correct 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.
Question 5: 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?
- Delete the entry and re-document it correctly
- Discuss with the trainee and ensure the entry is corrected with the actual date and time noted (Correct answer)
- Report immediately to the GMC without further discussion
- Accept the entry as it captures accurate clinical information
Correct 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.
Question 6: Which coding system is most commonly used in UK NHS psychiatric record systems for diagnostic documentation?
- DSM-5 codes
- ICD-10 codes (Correct answer)
- SNOMED CT only
- Read codes version 3
Correct answer: ICD-10 codes
ICD-10 codes are the standard diagnostic coding system mandated for NHS clinical records and commissioning data in the UK.
Question 7: A patient is admitted informally but later objects to continued admission. What documentation must be completed before any change in legal status?
- A written record that the patient has been informed of their right to leave and a capacity assessment (Correct answer)
- Only a verbal note in the patient's file
- A Section 17 leave form
- A Community Treatment Order application
Correct 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.
MRCPsych Documentation and Record Keeping 3
A patient refuses to sign their CPA care plan.
What is the recommended documentation practice?