LAUSR

Aims To devise and implement a new documentation sticker to be used by the CAMHS team (child and adolescent mental health services) in the Paediatric Emergency Department medical notes. To clearly document safety plans, diagnosis and follow up to the hospital and community teams co-caring for mental health patients. Method Twenty sets of notes were taken at random from the year 2017–2018. The documentation of information in the notes, written by the CAMHS team, and quality of the discharge letter, written by the Emergency Department medical team, were assessed. The CAMHS sticker was introduced for the CAMHS team to use to document their assessment. Twenty sets of notes were assessed after the implementation of the CAMHS sticker. Results There was improved documentation after the implementation of the CAMHS sticker in the notes. Specifically, the CAMHS team documentation of their assessment (Pre 40%: Post 85%), management plan (Pre 70%: Post 100%) and risk assessment (Pre 30%: Post 90%). The quality of the emergency department discharge letter also improved for diagnosis (Pre 90%: Post 95%) and risk assessment (Pre 30%: Post 70%). However, there was a fall in documentation in the management plan in the discharge letter (Pre 90%: Post 55%) for reasons unknown. Conclusion The introduction of the CAMHS sticker has improved documentation and communication between clinical teams and primary care. This can be seen in all areas in the notes and discharge letter. However, documentation of the management plan in the discharge letter needs to be refined. It was also noted that the name, contact number, date and time of assessment by the CAMHS team could be improved. A new sticker has been designed to include these demographics in order for clearer handover between the CAMHS team and the emergency department. The introduction and the positive effects the CAMHS sticker has had on the working relationship between the CAMHS team and the emergency department has been noted by the inpatient teams. The CAMHS sticker has now been revised by the inpatient teams in order for them to use for the mental health patients on the wards. A re-audit of the use of the stickers should be done at a later date to ensure compliance is improving as well as documentation.