The Online Journal of Clinical Audits, Vol 8, No 4 (2016)

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Copying clinical letters to patients’ in Intellectual disability: A Completed Audit Cycle

Solomon Shatananda, Nasim Chaudhry


Aims • Ascertain the practice of copying clinical letters as per General Medical Council (GMC), Royal College of Psychiatrist and Code of Practice guidelines.• Development of an ‘Easy Read’ as a service improvement project. • Re-Audit cycle following the implementation of ‘Easy Read.’

Methods A baseline audit was performed in August 2014 in the Salford Intellectual disability team to ascertain if patients or their carers were copied to the clinical letter. The evidence of this discussion with the patient was also checked retrospectively in the letters. The recommendations made were to develop an ‘Easy Read’ in collaboration with the patient’s forum and then to re-audit. A re-audit was done in September 2015 after the ‘Easy Read’ was approved and disseminated.
Results The baseline audit showed 16% of patients were copied while the re-audit showed an improvement by 54%. The percentage of carers remained the same at 94%. The documented evidence of this conversation was less than 6% in the baseline audit, while this improved to 55% in the re-audit.   If a patient lacked capacity, then the decision was taken based on best interest of the patient (15%).
Conclusions It’s a government policy in England to send clinical letters to patients as it includes patients as a partner in their healthcare, encourages greater openness and transparency and makes it in line with the ‘Data Protection Act 1998.’ Patients with Intellectual disability or mental illness are no exception to this. This is widely practiced in all specialities in Psychiatry but is particularly challenging in the intellectually disabled group.Our baseline audit helped to identify an area of our service shortfall. The dissemination of the results and recommendations helped improve the service provision. The development of the easy read helped the clinicians as an aid in explaining to the patient. 

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