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

Author:

Akerman Marco,McCarthy Mark

Abstract

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.

Publisher

Royal College of Psychiatrists

Subject

Psychiatry and Mental health

Reference5 articles.

1. Peer review as an aid to improving the completeness of psychiatric case notes

2. A management system to maximise compliance with standards for medical records;Casper;Hospital and Community Psychiatry,1987

3. Audit of psychiatric discharge summaries

4. A strategy for enhancing the clinical utility of the psychiatric record;Vort;Hospital and Community Psychiatry,1989

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