For all patients that we assess, we will request the clinical notes in advance and review these prior to conducting the assessment. This allows us to put together a record of someone's contact with mental health services and their previous admissions. It also allows us to summarise all the previous treatments that the person has received.

This is an essential part of our assessment process and it is difficult to make treatment recommendations without this information. However, there are often reasons that make it difficult, including:

1. Sending paper records that don't include all notes. Often, clinical psychology records (for example) are held separately and not sent.
2. Omitting to send notes from different services. For example, sending General Adult Psychiatry notes but not sending CAMHS notes.
3. Sending electronic notes that are not organised, sorted, grouped, or searchable.

Just because someone has fed all the notes into a scanner, it doesn't mean that the job is done. The notes are digitised but they're not automatically useable. In one case, we received hundreds of separate files with unintelligible names that weren't sorted by date, type, or service. It took hours to try and reorganise these into a coherent record of someone's treatment. In another case, we were sent four PDFs (taking up the best part of a Gigabyte) with scans of 15,000 pages. None of these were grouped by type of document (e.g. clinical corresondence) and you could not search within most of them (for a doctor's name, or a drug).

Getting dates right

It is not only desirable, but clinically important to ensure that documents are sorted by date. This ensures that events are understood in the order that they happened, and the amount of time spent trying to work out when doses of medications were changed (for example) is minimised.

Please note that the following documents will not sort as you might expect. In fact, they are completely out-of-sync, increasing the risk that information will be overlooked or  events will not be understood in the order that they occurred.

• 14-11-2023-Clinical-Notes.pdf
• 21-01-2025-Clinical-Notes.pdf
• 27-06-2023-Clinical-Notes.pdf

Whether these dates are entered in the filename, or if they are automatically sorted when compiling electronic notes, almost all computer systems sort in ascending order when reading from left-to-right. So the year becomes irrelevant and 1 Jan 2025 (o1-01-2025) will appear before 15 June 2019 (15-06-2019) and before 30 February 2006 (30-02-2006).

So, before you send notes please become familiar with how your electronic systems work, how your organisation names files, and have a look at what happens when you export large numbers of records. Please, please, please, check the dates.

General advice on sending notes

The following advice is hopefully helpful when making choices about how to send clinical notes. In most cases, patients will have a mixture of different types of notes.

Our preference is almost always original paper notes: they are easy to navigate, you can quickly identify different types of notes, and you can skim through them to find key information. They are usually organised logically and (in most cases) automatically sorted by date.

1) If you are sending original notes...

1. Please ensure that notes from all services and all time periods are included.
2. If your NHS Board keeps Clinical Psychology notes separately, please chase these up and make sure they are sent.
3. If the patient has had CAMHS involvement, please include these as well.

2) If you are sending paper copies of original notes...

1. It is incredibly helpful if different sections of the clinical case notes are identified and kept separate, just as they would be in the original notes. Dividers should be available and are not expensive.
2. Ideally, try to mirror the original sections of the clinical case notes. This would mean that clinical correspondence is separate from inpatient notes, investigations, and (in most cases) handwritten notes.

3) If you are sending scans of paper notes...

1. Please do not send very large files (e.g. containing thousands of individual pages). Break the notes down into chunks that are easy to send. Most people in the NHS have to use Acrobat Reader built into the browser, and this does not handle files containing thousands of pages well.
2. Please group files according to type of document, e.g. 'Clinical correspondence', 'Drug Kardexes', 'Nursing notes', 'Clinical Psychology notes'. You may wish to send everything, but we can only review the content we need if we know where to find it.
3. Documents should be sorted by date. Ascending or descending order is fine, but ensure that the order is consistent throughout. Please see above for more guidance on how to use dates.
4. OCR (Optical Character Recognition) is available in almost all scanning software, so please use it. It makes it much easier to find particular content. Be aware that OCR can sometimes make documents slightly larger, so please break-up files into manageable sizes (anything over 20Mb is probably too large).

If you are sending output from electronic records...

1. Ensure that documents are sorted properly by date (please see above).
2. Please rename files or attachments coming from your EPR to something sensible and recognisable. For example: '20231211_GAP_Consultant_Letter.docx' and not '111223-1515-0111792304-CMHT612-Attach-D3F7A3.docx'. Remember that it will be humans processing the information and not your original EPR. If your EPR doesn't do this automatically, you have either bought a poor EPR, you are not training staff, or you are not ensuring that staff upload documents in a useable way. Most EPRs are self-contained ecosystems and are not designed to provide clinical information to third parties.
3. Please use the same file type if possible. PDF is preferable and is much easier to manage than hundreds of .RTF, .DOC, and .DOCX files.
4. Wherever possible, bundle similar documents together. It is much easier to read through a single document of 150 pages than 75 documents each of two pages.
5. As above, please use OCR if you have clinical letters that should easily convert to readable and searchable text (i.e. typed letters). In most cases, your EPR should be exporting documents that contain readable text. Do not try to apply OCR to handwritten documents.
6. Do not use high-resolution scans of documents that do not need it. Most EPRs should be able to export text documents as PDF, and a scan of a document that contains text but is no longer text defeats the point of having searchable text.

Conclusions

Storing and providing medical notes is a key responsibility of all NHS organisations. However, sending clinical information in formats that impose an excessive burden on those receiving them and may lead to information being overlooked means that this responsibility is not being met. The move to electronic records has made some things easier, but it has not solve the problem of how to provide clinical information that can be used effectively by those requesting the information.

Finally, please get in touch if you have any queries. If you are faced with 1000's of pages of documents, or files, we can often provide useful advice on what types of documents are most useful. This will save us (and you) time.