Here - Surrey and Borders Partnership NHS Foundation Trust

Audit of risk assessment
documentation in adult in-patients -
adherence to Trust guidelines and how
to improve performance in this area
By Abigail Crutchlow
Acknowledgements: Many thanks to Dr L Church for his help in finalising this document
Background
Current local policy for SABP NHS
Foundation Trust states that all adult
patients admitted to an in-patient unit
within the Trust should have a
standardised risk assessment form
completed on admission and this should
be updated regularly at every ward round
or if a significant change in risk occurs.
The aim of this audit is to provide an
overview of performance and whether
these guidelines are being met and, if
not, to implement methods to improve
performance. Through re-audit, the
benefit and impact of such interventions
and their role in the future will also be
assessed. Formal ethical approval was not
required for this audit as all data were
anonymous and patients were not
directly approached or involved in the
audit. The audit was registered and
approved by the Trust audit department.
Method
Initial audit
The initial audit included all current adult
in-patients on general adult wards at the
Abraham Cowley Unit, Chertsey. The
PICU unit was not included due to
altered level of risk for these patients.
Their notes were identified and their risk
assessment on admission and its
subsequent updates examined.
The following questions were asked:
1. Was a complete risk assessment
recorded on admission?
• This included a completed
comprehensive risk assessment
within 24h of admission
2. Has the risk assessment been updated
regularly /at each ward round?
• Occasional or irregular updates
were not considered satisfactory
• If the patient had been an in-patient
for a very short time and not yet
been seen on a ward round
(meaning regular updates may not
yet have commenced) then this was
noted and they were excluded from
question 2
3. Is the risk assessment accessible to
staff?
• Information needed to be clearly
visible in the appropriate section of
the notes
It was recorded whether all, some or
none of these three criteria were met for
each set of notes reviewed. The length of
stay, regularity with which the patient
was seen on a consultant ward round
and the team they were under were also
recorded, as these were identified as
possible factors that could influence the
results.
In order to meet the standard guidelines,
all three criteria needed to be met. The
data was then analysed and results
identified as below.
Research and Audit
Surrey and Borders Online Journal www.sabp.nhs.uk/journal 17