Background: The quality of admission clerking to psychiatry wards will influence initial management of patients suffering from mental illness. Incomplete clerking may put patient safety at risk.
Aims: We sought to assess the completeness of clerking to general adult psychiatry wards and to evaluate whether the introduction of an admission booklet would improve clerking.
Method: We analysed the completeness of clerking to general adult psychiatric wards by trainee doctors. Using an audit approach, the first phase assessed completeness of clerking when trainee doctors used continuation sheets to document the clerking in a free-hand manner. Thereafter, we developed a standardised admission booklet to document the clerking and assessed completeness of clerking in the second phase.
Results: The admission booklet significantly improved the completeness of clerking. Notable improvements were seen in multiple components of history taking and initial management, particularly in documenting risk to self and others.
Conclusions: Improving clerking by use of an admission booklet can lead to more informed management decisions particularly in regard to the patients' physical health and clinical risk management. This may consequently improve patient safety and help trainees communicate important aspects of the case to seniors and the wider multi-disciplinary team.