title: Medical Record Documentation in a Learning Disability In-patient Unit.
abstract: BACKGROUND
  Consistency in clinical structure and content is an important aspect of clinical practice. The rising demands on healthcare systems and associated costs require a much more efficient and transparent means of recording and accessing reliable clinical information in order to manage and deliver good quality care to patients.
  
  
  OBJECTIVE
  The audit has been completed with an aim to highlight the local standards set for medical record documentation and to assess if the outlined standards are being met in a learning disability in-patient psychiatric setting, the Coppice.
  
  
  METHODS
  Criteria based on GMC Good Medical practice guidelines (2013), RCPsych Good Psychiatric Practice (2009) and Records Management Policy.
  
  
  CONCLUSIONS
  Good practice was maintained for most parameters. Mild inaccuracies were noted with date of birth/ward name, timing and signatures.
  
  
  CONCLUSIONS
  This was presented locally and measures put in place to address the gaps. A re-audit should be performed within a year in order to complete the audit cycle and to ensure that the recommendations and action plan have been followed through.
authors.affiliation: Twinwoods Medical Centre, Milton Road, Clapham, Bedfordshire, MK417FL, Bedford, UK, Dthalitaya@yahoo.com.
authors.forename: Madhusudan Deepak
authors.initials: MD
authors.lastname: Thalitaya
authors.forename: Sujanita
authors.initials: S
authors.lastname: Thyagarajan
authors.forename: Vaishali
authors.initials: V
authors.lastname: Tirumalaraju
authors.forename: Emil
authors.initials: E
authors.lastname: Mihaylov
authors.forename: Marina
authors.initials: M
authors.lastname: Mihaylova
mesh_terms: D054869:Clinical Audit / Q000592:standards; D015897:Comorbidity; D004282:Documentation / Q000592:standards*; D004739:England; D006801:Humans; D008607:Intellectual Disability / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D008501:Medical Records, Problem-Oriented / Q000592:standards*; D011567:Psychiatric Department, Hospital / Q000592:standards*; D058996:Quality Improvement / Q000592:standards