Audit of handover documentation during patient transfers between learning disability psychiatry community teams

Abstract

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