作者: Ömür Budanur Miles
关键词: Psychiatry 、 Nursing 、 Audit 、 Documentation 、 Crisis plan 、 Learning disability 、 PATIENT TRANSFERS 、 Risk assessment 、 Duration (project management) 、 Handover 、 Medicine
摘要: AIMS AND METHOD The local experience of having to take over the care patients newly moved Bristol area revealed lack clear information on their complex needs. Official guidelines do not exist, therefore a consensus list expected handover was produced. records two were analysed in each six teams that agreed be audited. A standardised handover form devised and introduced (Part 1). Part 2 audit performed 18 months after implementation changes practice. RESULTS 1 diagnosis (11/12) medications (12/12) best-documented items during correspondence. Follow-up duration (3/12), crisis plan (3/12), professionals involved (0/12) risk assessment (3/12) if documented done so only for with complex showed improved documentation (11/11 first and 10/11 remainder). CLINICAL IMPLICATIONS Absent or concealed patient notes may contribute disruption continuity following transfers. use succinct, structured easily distinguishable records facilitate communication between professionals.