An Evaluation of the Performing and Recording of Physical Examinations by Psychiatric Trainees

Abstract

The physical examination on admission, as recorded in the psychiatric case notes, was assessed for 100 consecutive admissions under the age of 65. Assessment was made on the presence or absence of reference to 43 items of examination and the recording of the examinations was found to be uniformly poor. One of the authors re-examined 50 patients within 48 h of admission and the findings were then compared with the initial recorded examination. Significant unrecorded positive findings were most frequent in the neurological and locomotor systems.