Citation

Dick P, Durham T, Stewart M, Kane S, Duffy J. Psychiatr. Bull. 2003; 27(8): 298-300.

Copyright

(Copyright © 2003, Royal College of Psychiatrists)

DOI

10.1192/pb.27.8.298

PMID

unavailable

Abstract

Aims and method: The aim of the study was to assess the practicality of extracting past risk-related information from case records and to assess how this process might be cost-effectively incorporated in routine practice. Case records of 43 patients referred to the Care Programme Approach in Dundee were examined.

RESULTS: Our study yielded relevant information - 39% of patients had a history of violence, 58% of self-harm or suicide, 58% of severe self-neglect and 72% of non-compliance with medication. However, it took an average of 5 hours to conduct a thorough review of each case because the notes were bulky and poorly organised. Clinical implications: Retrospective review of conventional case records in routine practice is likely to be incomplete and misleading. Prospective recording should be practicable if used selectively, but requires a standardised approach to clijiical recording and case note maintenance. The risk recording system we developed, incorporating a dated index of incidents by risk category, followed by brief summaries of each incident, provides key clinical information not available from a simple check list while not sacrificing brevity.

Language: en