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Mental state examinations by psychiatric trainees in a community NHS trust: The importance of a standardised format

  • Oladimeji S. Kareem (a1) and Ceri-Anne Ashby (a2)
Abstract
Aims and Method

To investigate the recording of Mental State Examination (MSE) findings by psychiatric trainees as well as dating, timing and signing of entries into the clinical record. Data were collected from randomly selected case notes in three acute psychiatric units.

Results

There was an initial decline of MSE recording from 69% to 58% in the first re-audit. Introduction of a standardised format and involvement of consultant trainers in the supervision of MSE recording led to an improvement to 83% in the secondre-audit. Adherence to medico-legal standards also improved.

Clinical Implications

The introduction of an MSE format and consultant supervision of records improved the standard of MSE recording as well as basic medico-legal requirements by psychiatric trainees.

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Copyright
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.
References
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Aquiuna, C. & Warner, J. (1996) The Royal Free Hospital Handbook of Psychiatric Examination. London: Royal Free Hospital.
Fuller, D. S. (1994) Instructions for Writing the AMSIT. San Antonio, TX: University of Texas Health Science Centre at San Antonio.
Gelder, M., Gath, D., Major, R., et al (1996) Oxford Textbook of Psychiatry. (3rd edn.). Oxford: Oxford University Press.
Hoyte, P. (1998) Guidelines for Good
Hoyte, P. (1998) Modernising Mental Health Services: Safe, Sound and Supportive. London: The Stationery Office.
Thomb, A. (1995) Psychiatry for House Officers. (5th edn.). Baltimore, MD: Williams & Wilkins.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Mental state examinations by psychiatric trainees in a community NHS trust: The importance of a standardised format

  • Oladimeji S. Kareem (a1) and Ceri-Anne Ashby (a2)
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