The study has addressed two strands: (i) the accuracy of record-keeping pertinent to drug prescribing for psychiatric inpatients, hence the implications on quality of care; (ii) the related contribution by junior doctors undertaking psychiatry placements. Within UK healthcare systems, these concepts are inextricable and have not been investigated previously. We found that nearly one-third of inpatients with mental illness lacked any prescribing documentation in their ward rounds especially those with SMI. Junior doctors are considerably less likely to document the prescribing rationale for psychotropic than non-psychotropic drugs, curtailing over time as they progress in their placements.
3.1 Quality of medical records
The often absent prescribing documentation was surprising, given that new psychopharmacological treatments are normally started for inpatients. Previous US studies amongst people with schizophrenia mirror our findings, demonstrating less accurate medical records  and increasingly absent prescribing documentation for those with more severe symptoms relative to people with non-SMI . Inaccurate or absent documentation of treatment plans can have detrimental effects on patient, exposing them to futile future treatments or side-effects.
The inequity of health between people with mental illness and the general population is well documented . Our sample, in contrast displays a more optimistic picture, with the physical health of this population attracting increased attention. This may be an inadvertent consequence of the greater familiarity with non-psychotropic drugs amongst junior doctors , but may also reflect the successful outcomes of guidelines aimed at improving the physical health of people with mental illness . Paradoxically, early-career junior doctors may be shifting the focus towards physical health problems in people with mental illness, while unintentionally contributing to a reverse disparity of esteem between physical and mental health.
Studies evaluating medical records may potentially raise ethical issues related to patient consent to data access. However, the NHS has robust clinical governance frameworks in these instances, which were followed throughout during data collection, storage, access and analysis as per related NHS guidance , as potential risks have been deemed to be outweighed by benefit for patients as a result of ensuing service improvement.
3.2 Junior doctor-related factors and training implications
All ward round documentation was completed by junior doctors highlighting the medical hierarchy in the UK , implying that EMRs of people with mental illness are being increasingly shaped by these doctors. Junior doctors in general, consistently perceive lack of preparedness for undertaking duties post-qualification, citing limited confidence with psychosocial concepts  and prescribing-related documentation . The latter may be related to non-technical soft skills such as clinical reasoning and initiative, which normally attains maturity “on the job” . At this stage of their training, junior doctors may therefore underestimate the implications of “prescribing rationale” and accurate documentation on patient safety. Within general hospitals, junior doctors may lack the confidence to complete accurate prescribing documentation instructed by senior colleagues, feeling uncomfortable questioning clinical decision-making .
High levels of stress amongst FY doctors have been identified nationwide  and those undertaking psychiatry placements have highlighted their uncertainty with working with patients with mental illness . The combination of personal vulnerabilities and influences from mentally unwell patients, especially those with SMI, may therefore be overwhelming, affecting overall performance that declines during their placement .
The quality of medical records can be an indirect reflection of the quality of care, and in turn, inaccurate documentation may compromise patient safety . Nevertheless, junior doctors are generally aware of patient safety and successfully reflect on safety incidents in their professional portfolios . Psychiatrists are indeed ideally placed, by virtue of their training, to further nurture doctors during their earlier development .
3.3 Future considerations
The benefit of using standardised templates to enhance the quality of documentation of admission to hospital has been consistently highlighted , hence extending their use uniformly across EMRs may enhance the quality of prescribing documentation. Since 2012, FY 1 doctors undertake mandatory induction prior to their first placement, correlated with improved performance . Considerations for longer inductions at the start of each subsequent placement may be beneficial in the longer-term.
-Data collection was restricted to ward rounds – a formal setting potentially contributing to underperformance of junior doctors, but manual scrutiny of all other EMR entries would have been exhaustive and error-prone.
-We relied on a subjective assessment of documentation, mitigated by independent scrutiny by two authors, although there are no standardised tools for this undertaking.
-The study setting was circumscribed and the sample size relatively small, limiting generalisability. However, data were collected from four heterogonous centres with comparable participant characteristics, while participant variables were consistent with those of other inpatient services in England .
-The time-frame was short, albeit intentionally covering the entire final placement in the training year.
-Sub-group analysis according to junior doctor type was not conducted, given the small proportion of GPST-completed documentation
-Evidence suggests a correlation between medical school of graduation and self-perceived performance , but these variables were not available for evaluation.