Objectives: To evaluate the effect of a risk assessment tutorial on the adequacy of case note documentation in a general adult psychiatry setting.
Methods: A comparison of case note documentation of risk factors for violence prior to and subsequent to a risk assessment tutorial.
Results: Prior to the tutorial there were very low rates of documentation of risk of violence. Subsequent to the tutorial, statistically significant improvements in documentation occurred in approximately one third of the items being assessed. Significant improvements occurred in the following; recording a collateral history (from 18%-36%) and previous history of deliberate self harm (from 24%-50%), noting emotions related to violence in the mental state examination (from 2%-24%) and documenting a risk management plan (from 2%-28%). However, levels of documentation remained overall sub-optimal.
Conclusions: Some improvement in case note documentation can result from providing tutorials in risk assessment. However, the ideal format for teaching risk assessment needs to ascertained.
