Sending clinical notes to the AIS

For all patients that we assess, we will request the clinical notes in advance and review these prior to seeing the patient. 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. Knowing about the patient's presentation over time also allows us to tailor the assessment in advance. 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 are 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.

The problems of digitisation

Just because it is easy to feed notes into a scanner, it doesn't mean that the job is done. In one case, we received hundreds of separate files with unintelligible names that aren'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 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 them (for a doctor's name, or a drug).

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.

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 apart, just as they would be in the original notes. Dividers should be available and are not expensive.

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.
2. Please name your files sensibly, for example: 'JOE_BLOGGS_CLINICAL_CORRESPONDENCE_JAN-2014_TO_DEC-2016'.
3. 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.
4. Ensure that documents are sortable by date.
5. OCR (Optical Character Recognition) is available in almost all scanning software, so please use it. It makes it much easier to find particular content, such as when drugs and doses are changed.

If you are sending output from electronic records...

1. Please make sensible choices about date format. '20250501_OP_Appointment.docx' will sort differently from '01052025_OP_Appointment.docx'.
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 reading the information and not your original EPR.

Conclusions