MRCPsych Documentation and Record Keeping 3

Question 1

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

Accepted Answer

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

Answer

Delay implementation of the care plan until consent is obtained

Answer

Obtain a court order before proceeding

Answer

Complete a Mental Health Act assessment immediately

Question 2

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

Accepted Answer

CR182

Answer

CR166

Answer

CR216

Answer

CR100

Question 3

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

Accepted Answer

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

Answer

Protective factors are irrelevant to risk; only risk factors matter legally

Answer

They are only required if the patient is being discharged

Answer

Documentation of protective factors is optional under NICE guidelines

Question 4

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

Accepted Answer

20 years from last contact or 10 years from death

Answer

7 years from last contact

Answer

8 years from last contact

Answer

Indefinitely, as no destruction is permitted

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?

Accepted Answer

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

Answer

Delete the entry and re-document it correctly

Answer

Report immediately to the GMC without further discussion

Answer

Accept the entry as it captures accurate clinical information

Question 6

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

Accepted Answer

ICD-10 codes

Answer

DSM-5 codes

Answer

SNOMED CT only

Answer

Read codes version 3

Question 7

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

Accepted Answer

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

Answer

Only a verbal note in the patient's file

Answer

A Section 17 leave form

Answer

A Community Treatment Order application