Case series of physical examinations on psychiatric inpatients: Influence of a structured form on the quality of documentation. (2013)

• Record Type: Journal Article
• Authors: Murray, Jonathan; Baillon, Sarah
• Is Part Of: Journal of mental health. Volume 22:Number 5(2013:Oct.)
• Page Start: 428
• Page End: 438
• Publication Date: 2013
• Subjects: physical examination -- physical health -- mental illness -- psychiatric patients -- audit -- documentation -- structured form -- proforma; Mental health -- Periodicals; Mental health services -- Periodicals; 362.2
• DOI: 10.3109/09638237.2013.815329
• Languages: English
• ISSNs: 0963-8237

Abstract

Abstract : Background: There is a strong association between mental disorder and poor physical health. However, research indicates that the standard of physical examinations performed on psychiatric inpatients is not good. Aims: This study aimed to assess the completeness of the physical examinations performed by psychiatric trainees on an acute psychiatric inpatient unit. Method: A retrospective analysis of 236 sets of inpatient case notes was performed. The quality of the documentation was assessed using a 50-point scoring system based on the presence or absence of reference to various items of examination. Results: Eighty-five percent of the patients received a complete examination and 13% were not examined at all. The mean points score was only 20 out of 50, indicating that the overall standard of documentation was quite low. However, when a proforma was used rather than free text documentation, significantly more information was recorded. Conclusions: Most psychiatric patients are not receiving a thorough physical examination. An essential first step to address the problem would be to divide physical examinations into three categories according to the psychiatric setting and reach a consensus on a gold standard for each type. Standards could also be improved by the more widespread use of a well-designed proforma and greater supervision of psychiatric trainees' performance in this area.