Higher level documentation practices in forensic psychiatry

Previously covered were the generalities of ‘documentation‘ and the extraction of four key principles: clarity, context, clinical reasoning, and patient engagement. This article aims to get into the actual nuts and bolts of documentation. Good documentation is not for the sake of ‘showing good documentation’. Good documentation is inseparable from providing high quality care. NHS England states, “The main purpose of a patient record, whether handwritten or digital, is to support direct patient care. Other uses, e.g. for research and for legal reasons, are secondary. For records to be fit for purpose they need to of the required quality.”

Resources that explain how to demonstrate the four key principles in actual documentation in mental health services has not been found, after scouring the internet and journal databases for weeks. SOAP and BIRP formats may be fine in many services but may not be sufficient to address levels of accountability required in forensic mental health services.

Text based commentary on the fictional BIRP documentation. [Caution: this is not a judgement on the BIRP methodology]

Table of Contents

• Recap of accepted basics
• Accountable documentation
• At the interface with law and regulatory oversight
• Another hypothetical case study
  • A preferrable account of the same patient
  • Reflection on the above
• Padding the records
• The knowledge-performance gap
• Conclusion and takeaway points
  • Supplemental reading

Recap of accepted basics

It will be assumed in this article that the fundamentals below from the Medical Defence Union, have been done or that documentation will be guided by those basics.

• Complete
• Contemporaneous
• Clear and legible
• Entered for the correct patient
• Don’t include ambiguous abbreviations
• Avoid jokey comments
• Not tampered with
• Checked

Click to view NHS England’s expectations

In separate articles the particular nature of forensic psychiatry were covered. In decision-making in forensic psychiatry 15 key cognitive activities (click for popup) were discovered and it was noted that,

The documentation of decision-making in this field should capture not only the final decision but also the critical elements of the reasoning process. This should include:

• Rationale for the chosen course of action
• Key factors considered and balanced
• Competing principles or obligations identified
• Risks and benefits analysed
• Alternative options explored

Accountable documentation

Always it must be kept in mind, “Who are we documenting for?” Is it ‘the system’, the patient, the team, ourselves – all of the latter? Forensic psychiatrists and their teams work in a legal environment which overlaps with clinical care.

It cannot be overstated that in a high-stakes environment that frequently manages complex cases fraught with risk, that documentation must conspicuously demonstrate what was considered and balanced towards forming decisions. Our best efforts to control risks (to self or others) may well fail. It is important to prepare for failure. This is about proactive accountability – not merely ‘defensive practice‘. Hence documentation in forensic psychiatry is about recording what was done and the thought processes behind clinical decisions, especially when those decisions involve balancing complex factors and potential risks.

This shift of perspective from defensive documentation to a proactive approach emphasises transparency, sound reasoning, and professional accountability. This is particularly important in forensic settings where decisions can have significant consequences for patients and the public.

To achieve this level of accountable documentation, consider these principles:

• Risk assessment and management: Clear documentation of risk assessment processes, including the factors considered, the level of risk identified, and the rationale for the chosen risk management strategies. If risk to others is identified, document steps taken to mitigate those risks in line with professional duties of confidentiality.
• Decision-making frameworks: When making complex decisions, consider using established frameworks or guidelines and document how these were applied to the specific case. This demonstrates a systematic and evidence-based approach to decision-making.
• Balancing competing factors: In forensic settings, clinicians often need to balance competing factors, such as patient rights, public safety, and legal mandates. Document how these factors were weighed and prioritised in the decision-making process.
• Ethical considerations: Document any ethical dilemmas encountered and how they were addressed. This demonstrates a commitment to ethical practice and professional integrity.
• Contingency planning: Document contingency plans in case the primary treatment plan fails or the patient’s condition deteriorates. This shows proactive consideration of potential challenges and a commitment to ongoing risk management.
• Multidisciplinary input: In complex cases, document the input of other professionals involved in the patient’s care, such as psychologists, social workers, and legal professionals. This demonstrates a collaborative approach to decision-making.

By adhering to these principles, those working in forensic psychiatry settings can create documentation that not only reflects their clinical practice but also demonstrates their commitment to accountable and transparent decision-making. This approach not only strengthens clinical decision-making in the event of scrutiny but also contributes to improved patient care and public safety.

At the interface with law and regulatory oversight

Forensic psychiatry operates within a complex and often ambiguous intersection between medical practice and legal systems. This inherent duality creates a unique set of challenges and exposes the discipline to heightened scrutiny from both regulatory bodies and legal systems. Both groups look for evidence upon which decisions are made and the quality of decision-making. Forensic psychiatrists and their co-workers are therefore in a vulnerable position. One need only look into what happened in The Barrett Inquiry.

Several factors contribute to this vulnerability:

• Conflicting Interests: Forensic psychiatrists often face situations where the interests of their patients may conflict with legal or public safety concerns. Balancing these competing interests requires careful judgment and meticulous documentation that can withstand scrutiny from various perspectives.
• Legal Mandates: Forensic psychiatry practice is often governed by specific legal mandates, such as those related to confidentiality, capacity assessment, and risk management. Adhering to these mandates while providing ethical and effective care requires a profound applied understanding of the law and its implications for clinical practice.
• Court and Tribunal Involvement: Forensic psychiatrists frequently interact with courts and tribunals, providing expert witness or professional evidence (orally and in writing). Their opinions and actions may be subject to intense scrutiny and challenge by legal professionals, requiring robust documentation to support their assessments and recommendations.
• Public scrutiny: High-profile cases involving forensic patients can attract significant media and public attention. This can lead to increased scrutiny of clinical decisions and practices, underscoring the importance of transparency and accountability in documentation.
• Professional accountability: Forensic psychiatrists are accountable not only to their patients but also to regulatory bodies, professional organisations, and the broader legal system. Maintaining high standards of documentation is essential for demonstrating compliance with ethical guidelines and professional standards.

To mitigate these risks and navigate the complexities of this interface, forensic psychiatrists must:

• Possess a strong medico-legal foundation: A thorough understanding of relevant laws, regulations, and ethical guidelines is crucial for navigating the legal and medical aspects of practice.
• Prioritise clear and comprehensive documentation: Meticulous record-keeping that accurately reflects clinical assessments, decision-making processes, and risk management strategies is essential for demonstrating accountability and withstanding scrutiny.
• Engage in regular professional development: Keeping abreast of evolving legal and clinical standards through continuing education and peer consultation is crucial for maintaining competence and best practice.
• Seek expert consultation when necessary: In complex cases or situations involving conflicting interests, seeking guidance from experienced colleagues or legal experts can help ensure sound decision-making and mitigate potential risks.

Another hypothetical case study

Adding to the BIRP hypothetical is this entirely fictitious record that bears close resemblance to what is typically seen in forensic psychiatry. Such documentation is often seen as acceptable in general psychiatry. [Caution: the following is not intent criticising nurses in general or any particular team.]

A preferrable account of the same patient

Reflection on the above

Enhanced documentation in forensic psychiatry necessitates a greater investment of time and cognitive effort. This translates to a more substantial volume of text, reflecting the depth and breadth of clinical considerations.

The increased volume serves several key purposes:

• Precision: It allows for greater precision in describing observations, mental state, risk factors, and the decision-making process.
• Contextualisation: It provides richer context, enabling a more complete understanding of the patient’s situation and the rationale for clinical interventions.
• Transparency: It promotes transparency by clearly outlining the factors considered and the reasons behind decisions.
• Accountability: It strengthens the accountability of clinical practice by providing a robust record that can withstand scrutiny.

While the initial time investment may seem demanding, the long-term benefits outweigh the costs. Consider these advantages:

• Reduced medico-legal risk: Comprehensive documentation mitigates potential liability by demonstrating thoroughness and sound clinical judgment.
• Improved teamwork: Detailed records facilitate better communication among the clinical team, promoting continuity of care and collaborative decision-making.
• Enhanced patient care: A more complete understanding of the patient’s history, risk factors, and treatment rationale leads to more informed and effective care.
• Professional accountability: Accountable documentation reflects a commitment to professional standards and ethical practice.

Ultimately, the increased volume of text signifies a shift from perfunctory record-keeping to a more meaningful and accountable form of documentation. This shift requires a commitment from individual clinicians, as well as organisational support in terms of time allocation, training, and a culture that values thorough documentation.

Padding the records

Padding is about using terminology or descriptions that sound good. Padding does not contain the substance of evidence, robust description of observations, or clinical reasoning. Padders tend to substitute opinion for evidence-based reasoning. Padding is a more insidious issue than simply adding superfluous information. It can be a deliberate attempt to create a façade of clinical profundity, masking a potential lack of genuine insight or thoroughness in one’s assessment and decision-making.

Phrases like “in the best interests of the patient” and “clinically appropriate” can serve as rhetorical devices, giving the impression of careful consideration and expertise when, in reality, they may conceal a lack of specific attention. This practice can be particularly concerning in a medicolegal context, as it can mislead those reviewing the record, potentially obscuring critical details or raising doubts about the clinician’s transparency and accountability.

It appears that those who engage in padding may operate under certain assumptions about their audience and the scrutiny their documentation will receive. These assumptions are often flawed and detrimental in the long run.

• Firstly, they may assume that others will passively accept their statements without critical evaluation. This can be a dangerous presumption, as colleagues, supervisors, legal professionals, and even patients themselves are increasingly aware of the importance of thorough and transparent documentation. Generic pronouncements and unsubstantiated claims are likely to raise red flags rather than inspire confidence.
• Secondly, padders may believe that their opinions and interpretations will be accepted without challenge. This overlooks the fact that medical documentation is not merely a subjective narrative but a record intended to convey objective information and clinical reasoning. In a medicolegal context, opinions must be supported by evidence and a clear articulation of the thought process behind them.
• Thirdly, they may underestimate the potential consequences of inadequate documentation. Padding can create a false sense of security, leading clinicians to believe that they have adequately justified their decisions when, in reality, their records may lack the necessary detail and substantiation to withstand scrutiny. This can expose them to medico-legal risks and challenges to their professional credibility.

Ultimately, the practice of padding reflects a disregard for the fundamental principles of medical documentation. It prioritises appearances over substance, potentially compromising patient care and undermining the integrity of health care. Clinicians have an ethical and professional responsibility to ensure that their documentation is accurate, transparent, and reflective of sound clinical judgment.

The knowledge-performance gap

Real-world experience draws out that knowledge of all the principles does not mean performance and application. While education is essential in laying the foundation for good documentation practices, it is not sufficient to ensure consistent application in the real-world setting of forensic psychiatry. Knowledge alone does not translate into action. Bridging the knowledge-performance gap requires a multi-faceted approach that goes beyond simply imparting information.

Factors contributing to performance gaps:

• Time constraints: Forensic psychiatrists and their teams often manage heavy caseloads and face significant time pressures. Thorough documentation can be time-consuming, and clinicians may feel pressured to prioritise other tasks, leading to rushed or incomplete records.
• Cognitive burden: Decision-making in forensic psychiatry is cognitively complex, requiring the integration of multiple sources of information and the balancing of competing priorities. This cognitive burden can impact a clinician’s ability to meticulously document every aspect of their reasoning and decision-making process.
• Lack of immediate feedback: Unlike other areas of medicine where immediate outcomes may be apparent, the impact of documentation in forensic psychiatry may not be evident for months or even years. This lack of immediate feedback can reduce the perceived importance of detailed documentation.
• Electronic Health Record Systems: Some electronic health record systems can be cumbersome or poorly designed, hindering efficient and comprehensive documentation. Limited free-text entry options or a focus on structured data fields may not allow for the contextual documentation required in forensic settings.
• Team dynamics and culture: A team culture that does not prioritise or incentivise good documentation can undermine individual efforts. Lack of leadership emphasis on documentation standards or a perceived tolerance for incomplete records can perpetuate suboptimal practices.
• Training and supervision: Inadequate training on documentation skills and a lack of regular supervision focused on documentation quality can contribute to performance gaps. Clinicians may not receive sufficient feedback or guidance on how to improve their documentation practices.
• Emotional factors: Dealing with challenging patients and high-stakes situations can take an emotional toll on clinicians. This can impact their cognitive capacity and motivation for detailed documentation, particularly when facing fatigue or burnout.
• Overconfidence bias: Experienced clinicians may overestimate their ability to recall details later on, leading to a tendency to under-document their reasoning and decision-making process.

Addressing these barriers requires a multi-dimensional approach:

• System-level changes: Implement electronic health record systems that facilitate comprehensive documentation. Allocate dedicated time for documentation and reduce administrative burdens.
• Team culture: Foster a culture that values and prioritises good documentation. Provide leadership support and mentorship for documentation skills.
• Training and supervision: Integrate documentation skills training into continuing professional development. Provide regular supervision with a focus on documentation quality and feedback.
• Individual strategies: Clinicians can use checklists, templates, or voice recognition software to streamline documentation. Employ reflective practice techniques to enhance awareness of cognitive biases and improve decision-making processes.

Conclusion and takeaway points

In this comprehensive exploration of the fundamentals of good documentation in clinical practice, we have taken a deep dive into the nuances of clinical consultations and team meetings, particularly within the high-stakes environment of forensic psychiatry. It is not enough to simply document that discussions occurred; instead, the level of detail that accurately reflects the complexity of the decision-making process is transparently revealed.

Specificity is paramount. When documenting clinical consultations, it is important to go beyond perfunctory reference to content of discussions. Documentation should include the patient’s perspective, the rationale for decisions, and any disagreements or resolutions. In team meetings, it is essential to document key discussion points, decisions, actions, and the rationale behind those decisions. By embracing the principles of specificity, accountability, and transparency, we can elevate the standard of documentation in forensic psychiatry.

Forensic psychiatry demands a heightened level of accountability due to the inherent risks involved for patients, the public, professionals, organisations. Documentation must demonstrate consideration of all reasonable factors in decision-making and sound principles of reasoning applied. This is not merely defensive practice; it is a commitment to transparency and professional responsibility.

This exploration identified several factors that can hinder performance, including time constraints, cognitive burden, lack of immediate feedback, electronic health record systems, team dynamics, training, and emotional factors. Addressing these barriers requires a multi-level approach that combines education, skills development, system redesign, cultural transformation, and individual strategies.

Whilst recognising that resources of time and manpower are not endless, sufficiently supported individuals and teams perform at a higher level required of this complex area of work. The quality of documentation in forensic psychiatry, while reliant on individual practitioners’ understanding and skills, is profoundly influenced by the wider organisational and cultural context. Leadership that prioritises and champions meticulous record-keeping sets the stage for a team-wide commitment to this essential practice. Conversely, a lack of emphasis from those in charge can undermine even the most diligent individual efforts. Resources, including time allocation and the usability of electronic health record systems, must support, rather than hinder, thorough documentation. Overburdened clinicians working with cumbersome technology cannot be expected to consistently produce the contextually salient records required in forensic settings.

A collaborative team environment, where open communication and shared learning are encouraged, fosters a culture that values good documentation. Regular case discussions and peer review processes provide invaluable opportunities for feedback and improvement. Training should go beyond simply instructing ‘how’ to document, but also illuminate ‘why’ it matters, linking best practices to improved patient care, effective risk management, and professional accountability. Finally, recognising and rewarding excellence in documentation reinforces its importance and motivates clinicians to prioritise this vital aspect of their practice. A systemic approach that addresses these factors is essential to create a culture where thorough documentation is an integral part of high-quality care.

Supplemental reading

1. Effective record-keeping – the MDU 2024