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Why psychiatric discharge summaries do not contain the mental state examination at discharge

  • Marco Akerman (a1) and Mark McCarthy (a1)
Extract

In an era where computerised information is dominant, it may seem an eccentric enterprise to assess the quality of case-notes and to propose changes in the notekeeping process. There are no institutional incentives for clinicians to provide organised and standardised clinical notes (Casper, 1987) and there is no clear evidence that poor notekeeping means that satisfactory care has not been provided.

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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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Casper, E. S. (1987) A management system to maximise compliance with standards for medical records. Hospital and Community Psychiatry, 38, 11911194.
Craddock, N. & Craddock, B. (1990) Audit of psychiatric discharge summaries. Psychiatric Bulletin, 14, 618620.
Ellis, P. M. et al (1987) Peer review as an aid to improving the completeness of psychiatric case notes. Medical education, 21, 493497.
Siegel, C. & Fisher, S. K. (1981) Psychiatric Records in Mental Health Care. New York: Brunner/Mazel.
Vort, W. V. & Mattson, M. R. (1989) A strategy for enhancing the clinical utility of the psychiatric record. Hospital and Community Psychiatry, 40, 407409.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Why psychiatric discharge summaries do not contain the mental state examination at discharge

  • Marco Akerman (a1) and Mark McCarthy (a1)
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