Medical Notes – Auditing Tools

Forrest MLS have made it a practice to obtain and rigorously review medical notes of immigration detainees and ex-detainees. In doing so we have been struck by how often they contain valuable evidence which may warrant:

  • Instructions for a Medico-Legal Report
  • Instructions for a medical letter or visit by an independent doctor
  • A request for further consideration of release from detention on clinical grounds

On the basis of this experience we have produced an audit tool for IRC medical notes, which we believe will be helpful to many stakeholders. It is designed to be usable without clinical training, but should also be useful to doctors.

The tool consists of a series of questions which can be applied to printouts of IRC notes, leading to mainly binary or quantitative (and therefore unambiguous) answers.

The pro forma is attached as a Word document (for explanation and reference) and an Excel spreadsheet which can be can be filled out and lends itself to wholly anonymised collation.

We recommend that you trial it in appropriate cases and feedback your experience from this pilot to: audit1@forrestmls.org.

If you want a doctor to assess your findings on the form alone, please ensure that the patient is identified only by the unit number which your organisation has assigned to them.

If you and the patient want us to read their medical notes, please append a signed, witnessed, patient consent and the printout of the notes themselves.