Documentation Standards

Departmental Documentation

The following should be recorded by each ED:

  • The number of homeless ED attendances in the previous 3 months.
  • The number of homeless patients leaving ED prior to being seen by a clinician in the previous 3 months.

Documentation in Patients’ Notes

  • Drug and alcohol history
  • Past medical history, allergies, and medication
  • Social history including how long they have been homeless, which homeless services they use, where they sleep, if they have a key worker
  • Method of attendance e.g., ambulance, police, self and if by ambulance, the location where they were picked up

Standards in Relation to Discharge

  • The patient should only be discharged for GP follow up if they are registered with one.
  • Discharge plan for homeless people should be documented including how the decision has been affected by homelessness e.g., isolation, follow up etc.
  • Follow up plan for any of the vulnerable groups should be documented in the patient notes.
  • If sleeping rough, the patient should be referred to an outreach team.

Standards Which Apply to Drugs, Alcohol and Mental Health

  • The patient should be referred for specialist assessment if alcohol or drugs were the direct cause of the ED presentation.
  • If attending secondary to an alcohol related cause, a CIWA score should be documented before the patient leaves the department.
  • Homeless patients attending with alcohol as a cause of presentation should be given IV Pabrinex if indicated.
  • If there is an acute mental health problem identified, there should be a risk assessment documented and the patient should be referred to the mental health liaison team.

Learning bite

RCEM have developed a guideline which outlines several standards for the care of homeless and other vulnerable patients in ED. The fundamental standards relate to the duty to refer, providing patients with information and obtaining up to date contact details for patients.