Reflecting on an experience: recording of mental capacity audit

Using Gibbs' reflective cycle, a doctor considers how incomplete paperwork impacted on the treatment of a patient, and what they set about to change as a result.

Description

What happened?

I had a recent experience of some confusion about a patient's capacity to make a decision as the relevant documentation was not completed correctly in the patient's notes. Therefore I undertook an audit of the recording of mental capacity in patient notes.

Feelings

What were you thinking and feeling?

The situation I found myself in when the mental capacity form was not completed was difficult for me. It meant that a decision about what was in the patient's best interest was delayed which was distressing for both the patient and their family. I felt frustrated that this had happened because a colleague had not completed the documentation correctly. Whilst I didn't really want the extra work of completing an audit, I wanted to collect some evidence to assess whether this was happening across the Trust and was something that could be avoided in the future.

Evaluation

What was good and bad about the experience?

The good things:

  • the audit had a substantial sample size across a number of clinical areas
  • it was good experience to personally design and execute an audit
  • the audit did find evidence that there was inconsistent practice in the recording of capacity in the Trust which supported my assumption
  • the audit results are being used to inform further training in the Trust about measuring and recording capacity
  • it’s had a positive impact on patient safety and care.

The bad things:

  • the results of the audit were not good in terms of the implications for patients who lack capacity
  • the project was a bit ambitious for one person to complete
  • I was unaware of the regulations in terms of accessing data of patients who I was not providing care for - although this was highlighted to me before I started collecting data.

Analysis

What sense can you make of the situation?

Overall completing this audit was a positive experience in a number of ways. It helped me to take action and respond positively to a negative experience and I am hopeful that the audit results will be used to influence better patient care and medical practice in the area of capacity assessments. It has also highlighted to me the importance of accurate documentation to promote good continuity of care and treatment.

Beforehand I hadn't really given much thought to confidentiality issues and audit and it was good to familiarise myself with the GMC guidance on confidentiality on this issue.

Conclusion

What else could you have done?

I should have liaised more with the Trust governance team and accessed the support and expertise it offers in the planning and execution of the audit.

Action plan

If it arose again what would you do?
Next steps icon

My first point of contact would be to liaise with the Trust governance team to see how any planned audit fits into other audits being conducted. On a personal level I have improved my note keeping in patient documentation.