A key element of good in-patient psychiatric care is the multidisciplinary review, with accurate and legible recording of the outcome of the discussion. Traditionally, the junior doctor and nurse act as ‘scribes’ on the ward rounds, recording the outcomes in the multidisciplinary or separate medical and nursing notes. There are a number of ways in which this process can fail. First, the scribe may simply misunderstand the decision of the team, given the complexity and variety of decisions in a psychiatric setting. Second, the scribe may understand what to record, but what is written may be illegible. Finally, people present at the ward round can have different beliefs about what has been decided, but unless they immediately review what has been written, they may not realise the discrepancy. One or more of these failings can result in serious untoward incidents, such as a patient being allowed off the ward on unescorted leave when the responsible medical officer believed the team had decided against permitting such leave. It is only when there is a serious incident that discrepancies can and do emerge.
Use of the projector in ward rounds
Liquid crystal display (LCD) projectors are now widely used in postgraduate centres and lecture theatres. They allow the projection of a computer image on to a large slide screen or wall, and are often used in conjunction with presentation packages (such as Microsoft Power Point) or for educational activity, for example case presentations or journal clubs. However, these projectors can also be used to project any computer software onto a wall so that it can be read easily by all in the room. They are now relatively cheap (less than £1000) and easy to use, and are compatible with almost all personal computers.
The South London and Maudsley National Health Service Trust is relatively advanced in having access to an information system, Current Clinical Summary (CCS). Also most clinicians in the trust have e-mail, internet and intranet access. At the Ladywell Unit in Lewisham, we have piloted the use of an LCD projector with a networked personal computer connected to CCS to facilitate communication at the multidisciplinary review for an acute admission ward. Instead of writing in the notes, the ‘scribe’ (often the responsible medical officer) sits at the computer typing in the entry for the patient being discussed. During the discussion, previous correspondence, risk assessments, Health of the Nation Outcome Scale scores (Reference Wing, Curtis and BeevorWing et al, 1996), medication prescriptions and entries made by other members of the community team can be viewed on the wall. The availability of e-mail allows other clinicians to be contacted during the ward round, and the replies viewed by all if received in time. The community mental health team can be contacted to inform them of when discharge is planned, or to invite a care coordinator to the ward round. The direct entry of data into the information system during the ward round also allows instant communication to the community mental health team about the progress of patients while on the ward. An added benefit is that after each ward round the entry can be edited and revised each day, to serve as the basis of the discharge summary when the time comes. The equipment used consists of a standard trust personal computer linked to an LCD projector, which cost £850. A printer is available to print out copies of any document to insert in the paper notes if necessary. The review takes place in a medium-sized meeting room which seats up to 12 people around tables. The image is simply projected on the wall, and there is no need for the lighting to be dimmed.
Other benefits
In addition to the ward round, other meetings can benefit from the use of such technology. The projector is used at a daily meeting with the junior doctors when the weekly duty rota is displayed on the wall to check who is on leave, ill, on duty or attending training courses. The system can also be used to share information with the patients themselves, such as what has been recorded about them and why they have been placed on a section. In future, it might allow access to the British National Formulary or other expert systems to guide prescribing decisions.
The complete model used in our trust requires a reliable network and a reasonably fast information system; however, it would be equally possible simply to type notes into a Microsoft Word document. It also requires a member of the team to be able to type. Some of the benefits are dependent on the complexity of the format in which information can be entered into the system. CCS is a document-based database and so allows the inclusion of a rich narrative equivalent to written text in clinical notes. Information systems that are more record-based, with numerous check boxes, may not be as compatible with existing clinical processes. The CCS system allows much greater clarity and avoids problems of illegibility, as well as ensuring that all members of the team can review what is documented at the time. It also potentially allows greater collaboration in the production and wording of key documents such as risk formulations. There are obvious advantages for teaching and training medical and nursing staff.
Potential problems
There are some potential difficulties: there is a risk of slowing down the ward round if the network is playing up, the typist is slow or the system crashes. There is potential duplication, as some entries have to be put in paper notes until a process of complete electronic records is fully functional. Precautions have to be taken to prevent patients peering into the room and reading confidential information. There is a risk that the individual using the computer either becomes overly powerful or is prevented from contributing to the discussion fully because of being tied to the screen.
Conclusions
LCD projectors are a relatively mature and available form of technology, which offers considerable benefits for psychiatric practice, particularly in situations in which a group of mental health professionals need to make collective decisions that must be recorded accurately.
Declaration of interest
None.
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