Case series of physical examinations on psychiatric inpatients: Influence of a structured form on the quality of documentation

Abstract

Background

There is a strong association between mental disorder and poor physical health. However, research indicates that the standard of physical examinations performed on psychiatric inpatients is not good.

Aims

This study aimed to assess the completeness of the physical examinations performed by psychiatric trainees on an acute psychiatric inpatient unit.

Method

A retrospective analysis of 236 sets of inpatient case notes was performed. The quality of the documentation was assessed using a 50-point scoring system based on the presence or absence of reference to various items of examination.

Results

Eighty-five percent of the patients received a complete examination and 13% were not examined at all. The mean points score was only 20 out of 50, indicating that the overall standard of documentation was quite low. However, when a proforma was used rather than free text documentation, significantly more information was recorded.

Conclusions

Most psychiatric patients are not receiving a thorough physical examination. An essential first step to address the problem would be to divide physical examinations into three categories according to the psychiatric setting and reach a consensus on a gold standard for each type. Standards could also be improved by the more widespread use of a well-designed proforma and greater supervision of psychiatric trainees' performance in this area.

Keywords:

• physical examination
• physical health
• mental illness
• psychiatric patients
• audit
• documentation
• structured form
• proforma