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Structured psychiatric assessment schedules — treating the case notes and the patient

Brixton Community Mental Health Team, 308-312 Brixton Road, London SW9 6AA

Mark Amos, Mental Health Nurse and V. M. Mathew, Professor and Consultant Psychiatrist

Thames Gateway NHS Trust, The Little Brook Hospital, Archery Lane, Stone, Dartford, Kent DA2 6AU

AIMS AND METHOD

We surveyed the usefulness of a structured method of recording history and mental state examinations with a treatment plan in terms of conveying information about diagnosis and management, compared with informal methods of recording data. A survey of admission records by nursing and medical raters was followed by introduction of a standardised assessment format for use by trainees and a re-audit. Initial psychotropic medication was also scrutinised.

RESULTS

The assessment schedule improved clarity of diagnosis for the medical and nursing raters alike, but improvement in management plan quality was mainly apparent for the medical rater. The audit also exposed widespread use of hypnotic agents.

CLINICAL IMPLICATIONS

It is suggested that structured assessment schedules facilitate adherence to good standards of clinical practice and may benefit trainees undertaking professional exams as well as having a multi-disciplinary and medico-legal relevance.

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