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

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?

Accepted Answer

CR182

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

20 years from last contact or 10 years from death

Answer

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?

Accepted Answer

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

Answer

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.

(MRCPsych) Member of the Royal College of Psychiatrists Practice Test

(MRCPsych) Member of the Royal College of Psychiatrists Practice Test

MRCPsych Documentation and Record Keeping 3