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.
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.
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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