The issue of documentation has been covered from different angles before in: Documentation (June 2023), The Documentation Dilemma (Aug 2024), High level documentation practices (Oct 2024) and Decision-making (Oct 2024).
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Table of Contents
- Motivational preface
- Introduction
- Who needs to document to a high level?
- Unearthing the core determinants
- Documentation of conversations
- Conclusion and takeaway points
Motivational preface
This article gets into the granular areas of documentation, largely about form and content. This is different to the desirable standards of documentation. In other words in this article there is a search for the true fundamentals of documentation which is words on a page. What do the words mean? What do they explain, months or years down the road? What essential elements of use of language, demonstrates commitment and due diligence? Consider the findings of The Barrett Inquiry and The Coroner’s Findings in Daniel Harrison (in which documentaton or lack of it would have exposed failings).
Our records in forensic psychiatry are our tools, swords, and shields all at once. As tools, our records facilitate clinical care, guide risk management, and enable effective multidisciplinary working. They are the instruments through which we track progress, plan interventions, and coordinate care across complex systems. Well-structured documentation helps us navigate the intricate landscape of forensic mental healthcare, supporting both day-to-day clinical decisions and long-term treatment planning.
As swords, our records advance therapeutic objectives. They cut through complexity to demonstrate clear reasoning, establish robust care pathways, and advocate for appropriate patient care. Precise documentation can challenge incorrect assumptions, support legal arguments, and advance therapeutic goals within legal frameworks.
As shields, our records protect patients, professionals, and the public. They defend clinical decisions under scrutiny of inquiries and legal proceedings, demonstrate due diligence in risk management, and provide evidence of professional competence. Well-crafted documentation shields practitioners from unwarranted criticism while protecting patient interests and public safety.
This tripartite function of forensic documentation underscores why meticulous attention to both structure and detail is not merely good practice – it is essential for safe and effective forensic mental healthcare. Every entry in our clinical records must be crafted with the awareness that it may need to serve all three purposes simultaneously.
Introduction
I extract the deep essentials of documentation for bullet-proof clarity in forensic psychiatry. Clear, precise documentation holds particular significance in forensic psychiatry due to the complex intersection of mental healthcare, accountability to lawful third parties and legal scrutiny. Every clinical decision we make can have profound implications for patient care, public safety, and legal outcomes.
In forensic settings, our documentation must serve multiple purposes simultaneously. It must communicate clinical information to colleagues, demonstrate robust risk assessment and management, and stand up to intense examination in legal proceedings – whether by the CQC, GMC, Mental Health Tribunals, Criminal Courts, or Coroners’ Courts. The structured approach to documentation, using both broad frameworks and precise grammatical constructions, helps ensure our clinical reasoning is transparent and accountable.
The nature of forensic psychiatry means we often manage patients with complex presentations, serious offending histories, and other significant risks. Our decisions about detention, leave, observation levels, and risk management can have serious consequences if not well managed. Therefore, our documentation must clearly demonstrate the pathway of clinical reasoning that led to each decision. This includes showing how we balanced competing priorities, considered alternatives, and reached conclusions about risk and care.
When our records face legal scrutiny, perhaps years after the events they describe, they must stand alone in explaining our clinical decision-making. Precise language and clear documentation structures help ensure that third parties can understand not just what we did, but why we did it. This level of clarity protects our patients, the public, and our professional practice.
The robustness of documentation forms the bedrock of good communication and information transfer within and across teams e.g. for patient transfers and referrals.
Who needs to document to a high level?
Robust documentation in forensic psychiatry is a responsibility shared across the entire multidisciplinary team. Every team member – mental health nurses, healthcare assistants, occupational therapists, psychologists, social workers, staff who take minutes, to trainee doctors – plays a crucial role in creating a tapestry of clinical records.
Each observation, interaction, or intervention in forensic settings can be significant. A healthcare assistant noting a change in a patient’s socialisation patterns, a nurse documenting medication compliance issues, or an occupational therapist recording engagement in activities – all contribute to understanding risk patterns and mental state changes. These observations often become crucial evidence in serious incident reviews, inquests, or tribunal proceedings.
The structured approach to documentation should therefore permeate all levels of forensic service record-keeping. For instance, a nursing handover note describing a patient’s agitation needs the same clarity and precision as a psychiatric report. An occupational therapy assessment showing reduced engagement may provide vital evidence of deteriorating mental state. A social worker’s account of a family visit might reveal important risk information.
This shared responsibility for high-quality documentation creates a detailed tapestry of clinical information that supports safe, effective care while meeting legal scrutiny. When all team members document to these standards, it creates a robust clinical record that demonstrates the service’s comprehensive approach to patient care and risk management.
Unearthing the core determinants
Clinical documentation requires mastery of both broad structural elements and fine grammatical details. Think of it like painting – first laying down the major compositional elements, then adding the precise details that bring it to life.
The broad structural elements (big brush strokes) include:
- Relationship clauses – These are major structural components showing how events, observations and decisions relate to each other. They compare past with present, outline exceptions, and justify interventions. For example: “Whereas previous attempts at engagement were successful, current approaches require modification [because….…]“
- Temporal markers – These create the clinical timeline framework, establishing clear chronology and progression of care. For example: “Since admission, symptoms have progressively improved [from…] Currently, the patient demonstrates [specific granular detail…]“
- Contingent clinical planning – These outline the ‘if-then’ frameworks of care planning, showing clinical reasoning and forward planning. For example: “Should symptoms worsen, as evidenced by…, then the following measures will be implemented…“
The fine details (fine brush strokes) that support these include:
- Precise verb tense choices that show exact timing of events
- Active voice constructions that show clear responsibility
- Modal verbs demonstrating levels of clinical certainty
- Logical connectors showing clear reasoning paths
- Subject-verb clarity ensuring unambiguous meaning
| Big Brush Strokes | Examples (forms and content of explanation and balance) |
|---|---|
| Relationship Clauses – Past/Present Comparisons | “Whereas Mr Smith previously responded well to verbal de-escalation, his current presentation requires immediate pharmacological intervention [because…]” |
| Relationship Clauses – Clinical Exceptions | “Although the patient typically maintains medication concordance when well, his current paranoid state necessitates consideration of depot administration [because..].” |
| Temporal Markers – Timeline Establishment | “Since reducing clozapine three weeks ago, Mr Smith has shown progressive deterioration in his thought disorder [include evidence/observations].” |
| Temporal Markers – Current State | “Currently, Mr Smith exhibits intense paranoia, evidenced by his belief that ward staff are poisoning his food [e.g he said..“quote actual words”.].” |
| Temporal Markers – Future Planning | “Moving forward, daily psychiatric reviews will monitor his response to the restored medication regime [by the following means…].” |
| Contingent Planning – Threshold Definitions | “When Mr Smith demonstrates reduced agitation, as evidenced by decreased pacing and improved verbal engagement..[with vivid descriptions]” |
| Contingent Planning – Response Protocols | “Should his paranoid symptoms re-emerge, characterised by food refusal and staff accusations, immediate review will be conducted.” |
| Clinical Reasoning – Assessment Framework | “Having assessed Mr Smith’s capacity using the Mental Capacity Act framework, I determined he cannot weigh information about his treatment because…” |
| Clinical Reasoning – Decision Pathways | “Given the escalating risks of harm to others and the presence of active psychotic symptoms [described above], I have decided to implement Section 3 of the Mental Health Act. The documentation [above] considers options to detention. Due to the ‘nature’ and ‘degree’ the risks to self and others, it is unlikley that he can be treated outside of a hospital.” |
| Clinical Reasoning – Intervention Rationales | “The decision to increase observations to constant level was based on three factors [documented above]: his explicit repetitive threats to harm others, his recent attempts to leave the ward, and his increasing command hallucinations.” |
| Fine Brush Strokes | Examples (content of conclusive statements) |
|---|---|
| Active voice construction | “I assessed the patient’s mental state at 14:30 and determined that he requires immediate psychiatric review.” |
| Subject-Verb Clarity | “Dr Jones completed the risk assessment, identified three major risk factors, and implemented enhanced observations.” |
| Conjunctions for clinical context | “Although he engages well with female staff, he becomes hostile and threatening when approached by male nurses.” |
| Time-specific prepositions | “During the morning ward round, following multidisciplinary discussion, we agreed to commence supervised leave.” |
| Progressive tenses | “The patient is showing increasing signs of thought disorder, particularly when discussing his family relationships.” |
| If/Then donstructions | “If the patient maintains stability over the next 72 hours, then escorted ground leave will be reconsidered.” |
| Modal verbs of necessity | “The patient must remain under constant observations until the Home Treatment Team has completed their assessment.” |
| Sequential connectors | “Initially I reviewed his notes, subsequently conducted a mental state examination, and finally formulated the care plan.” |
| Causal connectors | “Because of his explicit threats to harm others, consequently I arranged immediate transfer to PICU.” |
| Parallel sentence structures | “He demonstrated reduced eye contact, displayed psychomotor agitation, and exhibited poverty of speech.” |
Documentation of conversations
Conversations with distraught relatives is a common scenario for forensic psychiatrists. It is difficult to take notes while concentrating on key elements of the conversation. Often times a forensic psychiatrist will ask a member of staff to take minutes.
Listen to the fictitious conversation as if it was happening live over the phone.
FP: Good morning Mrs. Smith. Thank you for taking time the call in to discuss John’s care today. I understand that you are quite concerned. With me on the speaker phone is Sarah Johnson – Ward Manager.
R: I’ve been waiting three weeks for this call! He doesn’t belong in there – he needs to be at home with me.
FP: I understand your concerns. Let me explain John’s current situation and treatment plan.
R: Treatment plan? He’s getting worse! Every time I visit, he’s drugged up. You’re just keeping him locked up and sedated!
FP: I appreciate your worry about the medication. John is prescribed carefully monitored doses to help manage his psychotic symptoms.
R: He never had these symptoms before he was sent there. It’s your hospital that’s making him ill. I know how to look after him.
FP: John’s symptoms were present before admission. In the three months before the incident, he had become increasingly paranoid, believing his father was poisoning his food. Despite your efforts to get him help, he had refused community mental health appointments.
R: Thats not true! Who’s telling you these lies!
FP: On the day of the incident, John’s acute psychotic symptoms led him to attack his father with a kitchen knife, stabbing him three times in the chest and abdomen. Your husband required emergency surgery at City Hospital and remained there for two weeks. The court, having considered the psychiatric evidence of John’s paranoid schizophrenia, made the Section 37/41 order because they recognised he needed treatment in a secure hospital rather than prison.
R: You’re all a part of the system!!
FP: I’m grateful if you could allow me to explain. The Ministry of Justice restriction order reflects the serious nature of the violence and the need to protect the public.
R: Don’t talk to me about courts! They got it all wrong. He was just confused that day. Anyone could have made that mistake. That wasn’t him! He loved his father. It was because he wasn’t sleeping and someone had given him some drugs. If he’d just been at home…
FP: I appreciate this is painful to discuss, but it’s important to acknowledge that John’s untreated psychosis led to nearly fatal consequences. We need to ensure his treatment prevents anything similar happening again. The index offence involved significant violence, Mrs. Smith. We have a duty to ensure John’s treatment reduces risk to both himself and others.
R: Risk? He’s never been a risk to me! You people just hide behind these fancy terms. I demand you discharge him now!
FP: I cannot discharge John. The Ministry of Justice must agree to any changes in his detention. Currently, his symptoms indicate he needs continued treatment.
R: This is ridiculous! I’m his mother – I have rights! My son has rights! I’m going to call my MP and get a lawyer!
FP: You have every right to seek legal advice and to contact your MP. John also has a right to tribunal where his detention can be reviewed independently.
R: Well, I’m not going to rest until you agree to release him. Your hospital is basically a prison – you’re no better than jailers!
FP: I understand you’re frustrated, but our priority must be John’s treatment and risk management. I’d like to end the call now. We can talk again.
R: There you go. You don’t give a shit about my son! [Slams the phone down]
MEETING WITH MRS SMITH (JOHNS MUM)
Date – Friday November 24 Present – Dr Brown and Mrs Smith (mother)
Mrs smith was angry about john being here. She thinks john should come home and dosnt agree with him being here. She says john is being drugged to much.
dr Brown talked about johns mental health and things about courts and explained about the section 37/41. Mrs smith got more angry about this and didnt agree with what happened in court.
The dr tried explaining about what john did but mum got realy upset and wouldnt listen properly. Something about john having psychosis and the incident with his dad was discussed but mum says it wasnt johns fault because he hadnt slept and maybe took drugs.
Mum says she has rights and is going to speak to her MP and get a lawyer involved she says john isnt a risk to anyone and we are just keeping him locked up for no reason.
The meeting ended with mrs smith being angry and saying she wont leave until we release john. Dr brown told her about tribunals.
Actions
- None agreed
- Mum very upset
- John to stay on section
Meeting finished at just before before lunch time.
This poor documentation:
- Lacks specific times/dates
- Has multiple spelling/grammatical errors
- Misses crucial clinical information
- Fails to capture the detail of risk discussions
- Provides no clear record of clinical decision-making
- Omits vital information about the index offence
- Doesn’t record the specific concerns raised
- Has no proper structure
- Doesn’t identify the minute taker
- Uses informal language
TELEPHONE MEETING MINUTES
Date: Friday 15th November 2024
Time: 10:00 – 10:20AM
Venue: Family Meeting Room, High Hills Forensic Service, Bammington Road, Figwater PQ9 5BP
Present:
Dr Elizabeth Brown (Forensic Psychiatrist)
Mrs Janet Smith (Patient’s Mother – JS)
Minutes: Sarah Johnson (Ward Manager) – constructed from a draft taken during the meeting.
Dr Brown opened the meeting by thanking Mrs Smith for attending to discuss John’s care.
Mrs Smith immediately expressed frustration about waiting three weeks for the call and stated her belief that John should be discharged home. She said: “He doesn’t belong there – he needs to be at home with me.”
When Dr Brown attempted to explain John’s treatment and detention, Mrs Smith interrupted, expressing concerns about medication levels. She stated: “Every time I visit, he’s drugged up. You’re just keeping him locked up and sedated!“
Dr Brown acknowledged Mrs Smith’s concerns and explained that John’s medication is carefully monitored and prescribed specifically to manage his psychotic symptoms.
Mrs Smith disputed the existence of symptoms prior to admission, stating: “He never had these symptoms before he went there. It’s your hospital that’s making him ill. I know how to look after him.”
Dr Brown then outlined the events leading to admission:
- Three months prior to the index offence, John developed increasing paranoid beliefs about his father poisoning his food
- He had actively refused community mental health appointments
- In an acute psychotic state, he attacked his father with a kitchen knife
- The attack resulted in three stab wounds to his father’s chest and abdomen
- His father required emergency surgery and spent two weeks in City Hospital
Mrs Smith rejected this account, stating: “That wasn’t him! He loved his father. It was because he wasn’t sleeping and someone had given him some drugs.”
Dr Brown explained that John’s Section 37/41 reflected the court’s recognition of his need for treatment rather than imprisonment. Mrs Smith strongly disagreed with the court’s decision, stating: “Don’t talk to me about courts! They got it all wrong.” Mrs Brown sounded angry in her tone of voice.
When Mrs Smith demanded immediate discharge, Dr Brown explained that Ministry of Justice approval would be required for any change in detention status. Mrs Smith responded by stating her intention to contact her MP and seek legal representation.
At 10:28 Mrs Smith, angrily shouted: “I’m not going to rest until you release him. Your hospital is basically a prison – you’re no better than jailers!“
Dr Brown maintained a professional approach, reiterating that John’s treatment and risk management remained the priority, and offered to discuss specific concerns. When Dr Brown politely ended the conversation Mrs Brown said at the top of her voice, “There you go. You don’t give a shit about my son!” and slammed down the phone.
Actions suggested by Dr Brown immediately after the call:
- Clinical team to continue current treatment plan
- Dr Brown to document discussion in clinical notes
- Team to await any contact from Mrs Smith’s legal representatives or the MP.
Minutes recorded by: Sarah Johnson
Ward Manager
Date: 15/11/2024 11:08AM
Comment: From these minutes Dr Brown is put at a real advantage because he has a number of good points that will jog his memory as he makes more detailed records of the conversation.
Conclusion and takeaway points
This publication assumed that documentation standards were being carried out, and went tremendously deeper into the roots of clarity when documenting. Professional documentation within forensic psychiatric settings demands meticulous attention to both structural frameworks and grammatical precision. This comprehensive approach to clinical record-keeping serves multiple purposes: it creates clear clinical communication, provides robust evidence of decision-making processes, and withstands legal scrutiny.
The framework for such documentation can be conceptualised as containing both ‘big brush strokes’ and ‘fine brush strokes’. The broader structural elements encompass relationship clauses, temporal markers, and contingent clinical planning. These provide the foundation for documenting complex clinical scenarios, risk assessments, and care planning decisions. Supporting these structural elements are the finer grammatical components, including active voice construction, precise verb forms, and logical connectors, which ensure clarity and prevent ambiguity.
Within forensic services, this structured approach to documentation holds particular significance due to the complex intersection of mental healthcare and legal requirements. Clinical records must simultaneously serve as contemporary healthcare documents and potential legal evidence. This dual purpose necessitates a shared understanding and implementation of documentation standards across all members of the multidisciplinary team.
The responsibility for maintaining such documentation standards extends beyond medical practitioners to encompass all professionals working within forensic services. Each team member’s observations and interventions contribute to the overall clinical picture and may prove crucial in inquiries or other legal proceedings. Therefore, the principles of clear, precise, and structured documentation should inform all clinical record-keeping within forensic services.
This systematic approach to documentation, when properly implemented, creates a comprehensive clinical record that demonstrates professional diligence, supports effective risk management, and provides a robust audit trail of clinical decision-making. Such documentation practices ultimately serve to protect patients, support professional practice, and maintain public safety within forensic psychiatric services.
