Adequacy of family history recording in psychiatric in-patient case notes

Abstract

The family history available in one hundred psychiatric in-patient case notes was compared with that obtained from one hundred patient interviews. Thirty-five relatives were also interviewed. Case notes contained a mean of 34% of the information available from patients. Relatives contributed only a small amount of additional information. Although 41 sets of notes were judged to be “inadequate” for the purposes of diagnosis, assessment and management, only four cases had missing information which may have influenced management.