Definition of Mental State Examination

Parkinson s disease was the

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 second re-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.

The Mental State Examination (MSE) is fundamental in psychiatric evaluations and, together with a good psychiatric history, forms the basis of accurate professional formulation, current diagnosis and consequent management. The study described here comprises an audit of MSE documentation within a community and mental health National Health Service (NHS) trust and two subsequent re-audits.

The overall aim of the study was to determine whether or not psychiatric trainees recorded the MSE as per agreed trust standards. The re-audit results also examined if psychiatric trainees append date, time, and signature to entries in the clinical record.

Literature

A thorough literature search showed that MSE recording differs in scope, heading, pattern and format from author to author (; ; ; ). There is, however, a consensus among clinicians that good medical practice involves appending appropriate date, time and signature to medical record entries. This basic medico-legal requirement has been re-iterated in a recent publication by the Medical Defence Union. No previous audit on this topic had been undertaken by the trust and no record of a similar study could be found on the audit database of the then Anglia & Oxford Region.

Standard for MSE recording

The appropriate recording of MSE findings is particularly important to psychiatric trainees both for examination purposes and in developing a tradition of sound documentation, which is necessary in the maintenance of seamless patient care and for medico-legal reasons.

In order to define an appropriate standard for the purpose of this study O.S.K. and consultant psychiatrists within the trust agreed, in consulation with a Royal College of Psychiatrists examiner, on a standard that MRCPsych candidates would be expected to meet at examination.

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Q&A

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Which organization coined the definition of health as a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity

Which organization coined the definition of health as a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity

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