Substance use amongst inpatients on mental health wards: practical guide for mental health services

Guidance for NHS health boards providing inpatient mental health services on responding to substance use on mental health wards. This should be used in conjunction with existing local guidance for responding to substance use incidents on inpatient wards.

16. Appendix D - Key information to record

The following is a comprehensive list of information to record using an incident reporting system when responding to incidents of substance use on inpatient wards.

  • Time / date of incident.
  • Exact location i.e. hospital, area, ward, room.
  • Name of patient / person involved.
  • Name and job title of witnesses
  • Description of item / packaging (e.g. white powder, tablets – colour / markings, number of).
  • What the substance may be suspected to be.
  • Where found – as accurate as possible (e.g. in right hand pocket of trousers).
  • How and where the substance has been stored.
  • Any other relevant information – e.g. CCTV? Other crimes to be reported?
  • Who passed the information to the police and when.

Staff should also record the incident report number (such as Datix), police incident number or crime reference number and/ or the enquiry officer details in the patient’s notes when describing the incident.



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