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

  • Declan Lyons (a1), Mark Amos (a2) and V. M. Mathew (a2)
Abstract
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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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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Audit Commission (1995) Setting the Record Straight, A Study of Hospital Medical Records. The Audit Commission: London.
Donnelly, P. (1995) Why trainees fail mock MRCPsych clinical examinations. Psychiatric Bulletin, 19, 302304.
Kareem, O. S. & Ashby, C. A. (2000) Mental state examinations by psychiatric trainees in a community NHS trust. The importance of a standardised format. Psychiatric Bulletin, 24, 109110.
O'Hare, T. (1995) Improvements in practice from assessing standards of recording psychiatric case-notes. Psychiatric Bulletin, 19, 352354.
Small, G. & Fawzy, F. (1988) Data omitted from psychiatric consultation notes. Journal of Clinical Psychiatry, 49, 307309.
World Health Organization (1992) The ICD–10 Classification of Mental and Behavioural Disorders. Geneva: WHO.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Structured psychiatric assessment schedules – treating the case notes and the patient

  • Declan Lyons (a1), Mark Amos (a2) and V. M. Mathew (a2)
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