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Why psychiatric discharge summaries do not contain the mental state examination at discharge

Published online by Cambridge University Press:  02 January 2018

Marco Akerman  and
Mark McCarthy
Marco Akerman
Affiliation:
Department of Community Medicine, University College and Middlesex School of Medicine, 66–72 Gower Street, London WC1E 6EA
Mark McCarthy
Affiliation:
Department of Community Medicine, University College and Middlesex School of Medicine, 66–72 Gower Street, London WC1E 6EA
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In an era where computerised information is dominant, it may seem an eccentric enterprise to assess the quality of case-notes and to propose changes in the notekeeping process. There are no institutional incentives for clinicians to provide organised and standardised clinical notes (Casper, 1987) and there is no clear evidence that poor notekeeping means that satisfactory care has not been provided.

Type
Training matters
Information
Psychiatric Bulletin , Volume 16 , Issue 4 , April 1992 , pp. 216 - 217
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 1992

References

Casper, E. S. (1987) A management system to maximise compliance with standards for medical records. Hospital and Community Psychiatry, 38, 1191–1194.Google Scholar
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Ellis, P. M. et al (1987) Peer review as an aid to improving the completeness of psychiatric case notes. Medical education, 21, 493–497.CrossRefGoogle ScholarPubMed
Siegel, C. & Fisher, S. K. (1981) Psychiatric Records in Mental Health Care. New York: Brunner/Mazel.Google Scholar
Vort, W. V. & Mattson, M. R. (1989) A strategy for enhancing the clinical utility of the psychiatric record. Hospital and Community Psychiatry, 40, 407–409.Google Scholar
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