Shared learning database

Oxford Health NHS Foundation Trust
Published date:
September 2013

A re-audit looking whether physical health assessments are being carried out and whether they are being documented in the correct place. The audit was carried out across all adult and older adult wards. Authors: Dr Hasanen Al-Taiar MBChB, MRCPsych (Specialist Registrar in Forensic Psychiatry) Dr Adil Nathoo (foundation doctor) Dr Sidra Shaheed (CT1 Psychiatry)

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The re-audit was aimed to investigate whether physical health assessment and VTE risk assessment were routinely completed and documented for the inpatients admitted to adult and older adult psychiatric units within Oxford Health NHS Foundation Trust. The results will be used to develop plans around the prevention and management of VTE in inpatients, in conjunction with the Medicines Safety Group committee.

Reasons for implementing your project

The recently issued NICE guidelines give a framework for assessment and management of VTE risk, and this has recently been introduced to Oxford Health NHS FT. This is a re-audit followed by an initial audit carried out in Sep 2011.

In July 2012 the National Safety Thermometer is being introduced on the Older Adults wards which also assessed the VTE Risk assessment. An audit was carried out in May 2012 and a re-audit was completed in Jan 2013.

How did you implement the project

The audit was completed in Jan 2013 using the electronic patient information system, RiO and evidence of physical examination was searched for in the core assessment section of RiO according to the new physical examination policy. Data collection focussed on assessing evidence that the physical health proforma has been completed and VTE risk identified. An audit tool (Appendix 1) was used for data collection with minimal patient details (RIO / NHS number) to ensure patient confidentiality.

Key findings

There is a general improvement in the documentation of the VTE risk assessment and Physical health assessment. There is a significant difference compared to 2011 results.

There was a good improvement (target 100%) in the documentation of the physical health assessments, this is clearly seen in 7 out of the 11 wards covered in the audit , compared to 5 wards which achieved the 100% target in 2012 reaudit.

We have achieved our goal in 4 out of 12 wards covered and that was reflected in the 100% rate of completing and documenting physical health assessments on the electronic case notes RIO system. There is a significant improvement in the completion and documentation of VTE risk assessments in Buckinghamshire parts of the trust across general adult and old age wards (90%, and 100% compared to 92% and 94% in 2012 audit).

There is a significant improvement Oxfordshire older adult wards in the completion and documentation of VTE risk assessments in the older adult wards in Oxfordshire (93% compared to 79% in 2012 audit).

Key learning points

1. We should be aiming at having our target of 100% achieved on all wards (both VTE and physical health assessment documentation).
2. Encouraging those clients who haven't had their psychical health assessment done to have it whilst they are still on the inpatient wards.
3. Ensure that all staff are aware that the physical health assessment needs to be documented in the correct place in RiO

Contact details

Hasanen Al-Taiar
Specialist Registrar in Forensic Psychiatry
Oxford Health NHS Foundation Trust

Tertiary care
Is the example industry-sponsored in any way?