Accurate and comprehensive documentation of consumer outcomes is critical for the planning, implementation and monitoring of effective mental health care.
This includes electronic and hard-copy documentation of all consumer assessments, care plans and reviews, as well as the updating of relevant electronic databases maintained by the individual mental health service.
Maintaining electronic databases
Mental health clinicians are responsible for collecting and entering the ratings for all consumer outcomes into their health service’s electronic database.
As self-assessments are voluntary for consumers to complete, most databases request the clinician to include additional details, such as whether the assessment was not offered (and why), was offered and refused, or was offered and completed.
Protecting consumer privacy
Consumer outcomes are governed by the same legislation and considerations as other clinical activities regarding the privacy and confidentiality of medical records and personal information.
In an adverse event or processes concerning freedom of information, clinicians may be required to justify incomplete, inaccurate or inconsistent consumer outcome records. For this reason, it is advised that clinicians complete these records themselves – rather than delegating the task to administrative staff.
If clinicians are not responsible for data entry, they need to ensure that the forms are:
- complete – do not leave clinician measure items empty, as these forms are clinical documents and it is not appropriate for administrative staff to be making a judgement attributing a code for incomplete measures
- legible, to ensure accurate data entry
Ensuring consistency with clinical files
Clinicians should ensure that all the consumer outcomes they record electronically confirm or correspond with the information contained in the consumer’s clinical file.
When documenting the offering or completion of a consumer self-assessment, it is important to detail:
- When: the date and amount of time taken. If it takes a long time to explain and assist the consumer to complete the assessment, this may be an indication of the level of support required, the impact of their illness, or their level of engagement with the service.
- What: the items that (a) indicate areas of concern identified by the consumer, (b) were left blank, and (c) are different from corresponding areas rated by the clinician.
- Action: what are the next steps; for example, present to clinical review, review care plan or involve associated supports? It is important that there are clear plans to follow up with consumers after their participation in the self-assessment process, regardless of whether they refused or only partially completed the measure.