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Accuracy of prescribing documentation by UK junior doctors undertaking psychiatry placements: a multi-centre observational study

Authors
  • Dey, Mrinalini1
  • Buhagiar, Kurt2
  • Jabbar, Farid2
  • 1 University of Liverpool, Institute of Ageing and Chronic Disease, Liverpool, UK , Liverpool (United Kingdom)
  • 2 East London NHS Foundation Trust, Research Department, London, UK , London (United Kingdom)
Type
Published Article
Journal
BMC Research Notes
Publisher
Springer (Biomed Central Ltd.)
Publication Date
Sep 04, 2019
Volume
12
Issue
1
Identifiers
DOI: 10.1186/s13104-019-4596-2
Source
Springer Nature
Keywords
License
Green

Abstract

ObjectivesMedical records are critical to patient care, but often contain incomplete information. In UK hospitals, record-keeping is traditionally undertaken by junior doctors, who are increasingly completing early-career placements in psychiatry, but negative attitudes towards psychiatry may affect their performance. Little is known about the accuracy of medical records in psychiatry in general. This study aimed to evaluate the accuracy of Electronic Medical Records (EMRs) pertinent to clinical decision-making (“rationale”) for prescribing completed by junior doctors during a psychiatry placement, focusing on the differences between psychotropic vs. non-psychotropic drugs and the temporal association during their placement.ResultsEMRs of 276 participants yielding 780 ward round entries were analysed, 100% of which were completed by Foundation Year or General Practice specialty training junior doctors rather than more senior clinicians. Compared with non-psychotropic drugs, documentation of prescribing rationale for psychotropic drugs was less likely (OR = 0.24, 95% CI 0.16–0.36, p < 0.001). The rate of rationale documentation significantly declined over time especially for psychotropic drugs (p < 0.001). Prescribing documentation of non-psychotropic drugs for people with mental illness is paradoxically more accurate than that of psychotropic drugs. Early-career junior doctors are therefore increasingly shaping EMRs of people receiving psychiatric care.

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