Clinical documentation audit of health care records within NHS Lothian Community Learning Disability Teams

Aims - We aim to increase the quality of multidisciplinary record keeping within the NHS Lothian Learning Disability service and the South East Scotland and Tayside Learning Disability MCN. Our other aim was to reduce exposure to legal and or clinical risk within NHS Lothian Learning Disability Service and the South East Scotland Learning Disability MCN. Methods - In 2009/10, a comprehensive audit tool approved by the local Clinical Governance Support Team was used on the Learning Disability Inpatient Service case notes to review the record keeping against standards and policy for documentation in healthcare records for NHS Lothian.  Using this tool we carried out Phase 1 of this audit in August 2013 on the outpatient case notes in 4 sectors of the NHS Lothian Learning Disability Service.  These results were then presented at the MCN Learning Disability Journal Club and NHS Lothian's documentation standards discussed. We completed the audit cycle during March 2014 using a modified audit tool with insights gained from phase one including review of correspondence. We collected data from outpatient case notes within NHS Lothian Learning Disability Service during this period. A total of 210 case records (120 - first phase; 90 - second phase) were perused. Data collected were transformed into graphs using Microsoft Excel. Results - The second phase of the audit shows significant improvement in clinical documentation practices within the Learning Disability Service in comparison to phase one. Conclusions - From phase 1 it was clear that every individual has their own view of record keeping standards.  The reaudit of the case notes showed that by promoting the universal standards set by NHS Lothian and presenting and distributing the results of this audit to the medical staff for the South East Scotland Learning Disability MCN a clear improvement is seen in clinical record keeping.