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

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.