State Examinations

At the State Examinations

Junior psychiatrists notes were compared before and after the use of a template.

Template notes were rated as more thorough, organized, useful and comprehensible.

An audit revealed template notes contained more clinically relevant information.

Objectives

The mental state examination (MSE) provides crucial information for healthcare professionals in the assessment and treatment of psychiatric patients as well as potentially providing valuable data for mental health researchers accessing electronic health records (EHRs). We wished to establish if improvements could be achieved in the documenting of MSEs by junior doctors within a large United Kingdom mental health trust following the introduction of an EHR based semi-structured MSE assessment template (OPCRIT+).

Methods

First, three consultant psychiatrists using a modified version of the Physician Documentation Quality Instrument-9 (PDQI-9) blindly rated fifty MSEs written using OPCRIT+ and fifty normal MSEs written with no template. Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT + MSEs.

Results

PDQI-9 ratings indicated that the OPCRIT + MSEs were more ‘Thorough’, ‘Organized’, ‘Useful’ and ‘Comprehensible’ as well as being of an overall higher quality than the normal MSEs. The audit identified that the normal MSEs contained fewer mentions of the individual components of ‘Thought content’, ‘Anxiety’ and ‘Cognition & Insight’.

Conclusions

These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs. Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.

Keywords

  • Mental state examination;
  • Electronic health records;
  • OPCRIT+;
  • Psychiatry;
  • Junior doctors;
  • Documentation;
  • National Health Service;
  • Semi-structured;
  • Audit

1. Introduction

The primary purpose of medical records is communication amongst the healthcare team, to enable seamless patient care, and . However, they also provide an important source of managerial, financial and statistical information, a source of evidence in the event of litigation and a potentially valuable resource for teaching and research, and .

You might also like

Authorized Settings for the Provision of Licensed Mental
Authorized Settings for the Provision of Licensed Mental ...
Arizona State Board Practical Exam for Esthetics (Updated
Arizona State Board Practical Exam for Esthetics (Updated ...
DVD 60: Mini-Mental State Examination
DVD 60: Mini-Mental State Examination
Arizona State Board Practical Exam for Esthetics
Arizona State Board Practical Exam for Esthetics
Encyclopedia of Counseling Package: Encyclopedia of Counseling: Master Review and Tutorial for the National Counselor Examination, State Counseling ... Preparation Comprehensive Examination
Book (Routledge)

Q&A

avatar
Describe possible reasons why Holden gets into a fight with Stradlater. What is Holden's mental state at this point? - Homework Help - eNotes.com

The first thing that upsets Holden before the fight is Stradlater's reaction to the essay about Allie's baseball glove which Holden keeps with him. The glove is covered with Allie's poems and is probably the best keepsake That Holden has of his brother.


The other thing that is bothering Holden is the thought of Stradlater being alone with Jane Gallagher. Holden was obviously very fond of Jane and shows some irritation when Stradlater refers to her as "Jean". Holden asks Stradlater "What'd you do?" "Give her the time in Ed Banky's goddam car?"  Holden says his voice was "shaking somethi…

Copyright © . All Rights Reserved