Psychiatric Bulletin (2001) 25: 418-420. doi: 10.1192/pb.25.11.418
© 2001 The Royal College of Psychiatrists
Psychiatric Bulletin (2001) 25: 418-420
© 2001 The Royal College of Psychiatrists
Structured psychiatric assessment schedules — treating the case notes and the patient
Declan Lyons, Specialist Registrar
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
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Abstract
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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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Introduction
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A high standard of clinical record keeping is a hallmark of good
psychiatric practice. Case notes are not just
aides-mémoires for doctors but are complex
documents that can be used for teaching, research and clinical audit, as well
as evidence in the event of litigation. Information obtained when a patient is
admitted informs the whole diagnostic and care planning process, including
risk management strategies. Psychiatric trainees at our trust presently employ
informal methods of clerking patients at admission, using hospital
continuation sheets, without adhering to a uniform style. The degree of
comprehensiveness of a recorded case history may depend on a variety of
factors, not least trainee experience, enthusiasm and the extent to which
future involvement with the patient is anticipated. It also follows that
admission notes will point towards a diagnosis and impart a clear treatment
plan to a greater or lesser extent. We wished to determine in our survey how
clinically relevant a structured assessment schedule would be as opposed to
present unstructured methods of clerking patients? Did this promote a clearer
understanding of diagnosis and management issues as rated by a psychiatrist
and a mental health nurse?
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The standard
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Incentives for trainees to attain a high standard of documentation of the
history and mental state may be provided by the standard required for Royal
College of Psychiatrists' (Instructions to candidates available from The Royal
College of Psychiatrists' Examinations Department, 17 Belgrave Sq, London SW1X
8PG) examinations because candidates have been noted to do poorly in clinical
examinations when, for example, they stray outside standard classification
systems or employ nontechnical terms to describe the diagnosis
(Donnelly, 1995). In the
day-to-day context, however, absence of key items of information can imply
that important aspects of patient management have not been considered and this
may have obvious patient care and medico-legal implications
(Audit Commission, 1995).
Previous local standards of structured documentation within the trust were
inspired by the Care Programme Approach. The resultant 16-page assessment form
proved unpopular because of its size and had been abandoned for over a year
prior to our survey.
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The study
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The survey was undertaken within the adult mental health services of Thames
Gateway NHS Trust, encompassing the catchment areas of Dartford and Gravesend
over a 4-month period and focused on 100 admissions to the acute admissions
unit. A structured assessment schedule was designed by the first author (D.L.)
in consultation with the psychiatric trainees, a College examiner and the
Clinical Audit Committee. It was hypothesised that adherence to the assessment
form and the compilation of a management plan would not only document each
episode of care but indirectly prove beneficial to trainees taking
postgraduate examinations, although this was not assessed here.
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Method
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Fifty consecutive discharges were subjected to a retrospective case note
survey and rated independently by a specialist registrar in psychiatry (D.L.)
and a registered mental nurse (M.A.). Criteria were defined and a standard
agreed for a rating form that reflected key information that should have been
discernible from the admission notes. Each set of admission notes was rated on
a five-point Likert scale according to their compliance with the criteria
(namely agreement or otherwise with the statements) below.
- From the admitting officer's notes a likely diagnosis is implied (full or
strong agreement implying a formal ICD-10 diagnosis).
- A diagnosis is implied 1 week later (full agreement as for first criterion
but completion of schedule deferred for up to 1 week as admission data may be
unobtainable on first assessment).
- From the admitting officer's notes a clear treatment plan is evident (full
agreement implying detailed investigations and treatments touching on
biological, psychological and social aspects).
- From the admitting officer's notes admission to hospital was the most
appropriate form of action (full agreement implying significant risk and/or an
emergency presentation).
- Risk was evaluated and documented in a clear fashion (full agreement
implying clear description of risk past and present and the obtaining of
collateral information).
- Management plan contains clear instructions to militate against risk (full
agreement implying clear stating and justification of precautions such as
observation level).
Initial prescribed psychotropic medication was also recorded.
A six-page structured assessment form was then introduced, with feedback
from trainees - invited to decide which categories of information should be
included in a document that was to have utility for emergency and elective
admissions alike. The last two pages were the main focus of the audit, where
trainees had to fill out the categories of differential diagnosis,
investigations and a management section with subcategories embracing physical,
biological and social aspects. Trainees were asked to document all initial
medication prescribed and to highlight the level of risk (estimated likelihood
of self-harm and or violence to others) and measures to address this, such as
nursing observations. A further 50 admissions were prospectively rated (also
according to the above criteria) in a second audit that was started
immediately after introduction of the assessment schedule. Physical
examination was not looked at in our survey as it was the subject of a
separate trust-wide audit.
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Results
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The introduction of the structured assessment schedule improved the
imparting of information concerning diagnosis (giving a clear ICD-10 category
(World Health Organization,
1992) or indicating a looser description) from 52% for the medical
and nursing raters in audit one to 98% by the re-audit (see Tables
1 and
2). The clarity of the
treatment plan was, for the medical rater
(Table 1), facilitated by the
use of the form with satisfactory or agree and superlative or strongly agree
ratings rising from 34% to 56%. Risk documentation and amelioration for the
medical rater improved from 36% and 78%, respectively, (also taking agree and
strongly agree ratings together) to 52% and 90%, respectively, with use of the
schedule. The nursing rater's estimation of the clarity of the treatment plans
was not enhanced by the use of the schedule, nor was the documenting of risk
(Table 2). The overall
appreciation of measures to counteract risk rose by only 2%, although
superlative scores from the nurse rater climbed by 12% when the schedule was
employed.
The prescribing of ‘as required’ zopiclone was found to be
widespread, with 57% of all acute admissions being charted for this agent.
Lorazepam on an ‘as required basis’ was charted for 28% of all
admissions and like the hypnotics no attempt was made by any trainee to time
limit this prescription, although individual doses had been restricted to a
maximum amount in a given 24-hour period.
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Comment and clinical implications
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We believe that use of a structured assessment schedule has encouraged
trainees to commit themselves further in stating a likely diagnosis for a
given admission as well as outlining a more detailed management plan that was
described by informal methods of clerking admissions. Consequently those
reviewing case notes are likely (almost twice as likely for diagnosis in our
survey) to have a clearer understanding of these issues. Rates of completion
of other data categories in the schedule were not studied here and it was left
to consultants within individual teams to ensure accuracy was maintained in
documenting, for example, mental state examination findings. Such
consultant-led supervision of records has been previously shown to be useful
not only for verification of clinical findings but also in improving standards
of data recording (Kareem & Ashby,
2000). The schedule may help to bridge the gap between
professional exams and day-to-day clinical practice as the categories we
audited are relevant for any clinical postgraduate examination and also
reflect a high standard of patient care.
The schedule allowed for greater comprehensibility by the medical, as
opposed to the nursing, rater of the treatment plans outlined, but this does
not necessarily undermine its relevance in a multi-disciplinary context.
Nursing staff may look for different aspects of treatment plans in judging the
comprehensiveness of admissions records. Possible methodological limitations
include the absence of rater blindness to the purpose of the study, which
could partially explain the disparity between the two raters. The overall
changes highlighted after introduction of the schedule could also be
attributed to the audit process. The process of clinical audit can by itself
lead to improvements in standards of documentation
(O'Hare 1995) but in the face
of regular staff turnover may not harness durable quality assurance. The
trainees were not informed of the second audit to minimise the effect of the
audit process and it is also significant that a changeover of junior doctors
occurred before the second audit began.
Omissions have been shown to be less frequent in consultation notes
delineating data categories (Small &
Fawzy, 1988), however, completion rates of the treatment plan
section of our form need to be improved. Almost half of the treatment plans
were still not being documented in sufficient detail. Further audit will be
required to establish if the improvements we have highlighted can be built
upon as trainees become accustomed to using the schedule. The widespread use
of hypnotics has caused concern and led to an immediate separate audit but the
primary finding of our study is the preliminary evidence of the usefulness of
structured assessment schedules, the discrepancy between nursing and medical
staff views of the completeness of treatment plans being a useful avenue for
further scrutiny.
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Acknowledgments
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We wish to thank John Wilkins and Sue Whitehead of the Clinical Audit
Department of Thames Gateway NHS Trust for their advice and assistance.
Copies of the assessment schedule employed in the survey are available on
request from D. Lyons, Brixton Community Mental Health Team, 308-312 Brixton
Road, London SW9 6AA.
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References
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AUDIT COMMISSION (1995) Setting the Record
Straight, A Study of Hospital Medical Records. The Audit
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DONNELLY, P. (1995) Why trainees fail mock MRCPsych
clinical examinations. Psychiatric Bulletin,
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KAREEM, O. S. & ASHBY, C. A. (2000) Mental state
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of a standardised format. Psychiatric Bulletin,
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109-110.[Abstract/Free Full Text]
O'HARE, T. (1995) Improvements in practice from
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Psychiatric Bulletin,
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SMALL, G. & FAWZY, F. (1988) Data omitted from
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WORLD HEALTH ORGANIZATION (1992) The ICD-10
Classification of Mental and Behavioural Disorders. Geneva:
WHO.
This article has been cited by other articles:
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S. Dinniss, J. Dawe, and M. Cooper
Psychiatric admission booking: audit of the impact of a standardised admission form
Psychiatr. Bull.,
September 1, 2006;
30(9):
334 - 336.
[Abstract]
[Full Text]
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Abstract
Introduction
