Improving the assessment of risk of violence: A clinical audit of case note documentation

Abstract

Aims and methods: To improve the rate of documentation of risk in new referrals to a community mental health team. A retrospective audit of 46 case notes was followed by a training session on risk of violence. The following 50 case notes were studied for changes in risk assessment. Results: Prior to the study there were very low rates of documentation of risk of violence. Significant improvements were made in 45% of the items in the history and mental state although not in the formulation of a risk assessment statement. Clinical implications: It is possible to improve the risk of violence documentation with no extra time, resources or paperwork and with true multi-disciplinary involvement.