The Accuracy of Medical Record Documentation in Schizophrenia

Overview

Journal J Behav Health Serv Res

Publisher Springer

Specialty Health Services

Date 2001 Dec 6

PMID 11732247

Citations 13

Authors

J Cradock

A S Young

G Sullivan

Affiliations

Soon will be listed here.

Abstract

Medical records are commonly used to measure quality of care. However, little is known about how accurately they reflect patients' clinical condition. Even less is understood about what influences the accuracy of provider's documentation and whether patient characteristics impact documentation habits. Discrepancies between symptoms and side effects evaluated by direct assessment and medical records were examined for 224 patients with schizophrenia at two public mental health clinics. Multivariate regression was used to study the relationship between patient, provider, and treatment characteristics and documentation accuracy. Overall, documentation of symptoms and side effects was frequently absent. Documentation varied substantially between clinics, and it was generally less likely for patients who were severely ill, black, or perceived as noncompliant. The accuracy and consistency of medical record documentation should be demonstrated before using it to evaluate care at public mental health clinics.

Citing Articles

Psychiatric Documentation in the 21st Century: A Trainee Perspective.

Lee A Acad Psychiatry. 2024; .

PMID: 39562480 DOI: 10.1007/s40596-024-02093-4.

A clinical decision rule predicting outcomes of emergency department patients with altered mental status.

Simkins T, Bissig D, Moreno G, Kahlon N, Gorin F, Duffy A J Am Coll Emerg Physicians Open. 2021; 2(5):e12522.

PMID: 34528023 PMC: 8432088. DOI: 10.1002/emp2.12522.

Accuracy of prescribing documentation by UK junior doctors undertaking psychiatry placements: a multi-centre observational study.

Dey M, Buhagiar K, Jabbar F BMC Res Notes. 2019; 12(1):558.

PMID: 31484585 PMC: 6727574. DOI: 10.1186/s13104-019-4596-2.

Adherence of 13-17 Year Old Adolescents to Medicinal and Non-pharmacological Treatment in Psychiatric Inpatient Care: Special Focus on Relative Clinical and Family Factors.

Timlin U, Hakko H, Riala K, Rasanen P, Kyngas H Child Psychiatry Hum Dev. 2014; 46(5):725-35.

PMID: 25307994 DOI: 10.1007/s10578-014-0514-y.

Predictors of recovery-oriented competencies among mental health professionals in one community mental health system.

Stuber J, Rocha A, Christian A, Johnson D Community Ment Health J. 2014; 50(8):909-14.

PMID: 24510273 DOI: 10.1007/s10597-014-9708-9.

References

Wallace C, Liberman R, MacKain S, Blackwell G, Eckman T . Effectiveness and replicability of modules for teaching social and instrumental skills to the severely mentally ill. Am J Psychiatry. 1992; 149(5):654-8. DOI: 10.1176/ajp.149.5.654. View

Young A, Sullivan G, Burnam M, Brook R . Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998; 55(7):611-7. DOI: 10.1001/archpsyc.55.7.611. View

Young A, Sullivan G, Duan N . Patient, provider, and treatment factors associated with poor-quality care for schizophrenia. Ment Health Serv Res. 2001; 1(4):201-11. DOI: 10.1023/a:1022369323451. View

Nowels A . A review of the medical records of adolescent psychiatric inpatients in a general hospital. Hosp Community Psychiatry. 1977; 28(12):903-6. DOI: 10.1176/ps.28.12.903. View

Miklowitz D, Goldstein M, Nuechterlein K, Snyder K, Doane J . Expressed emotion, affective style, lithium compliance, and relapse in recent onset mania. Psychopharmacol Bull. 1986; 22(3):628-32. View

Barnes T . A rating scale for drug-induced akathisia. Br J Psychiatry. 1989; 154:672-6. DOI: 10.1192/bjp.154.5.672. View

Jones S, Thornicroft G, Coffey M, Dunn G . A brief mental health outcome scale-reliability and validity of the Global Assessment of Functioning (GAF). Br J Psychiatry. 1995; 166(5):654-9. DOI: 10.1192/bjp.166.5.654. View

Pyne J, Bean D, Sullivan G . Characteristics of patients with schizophrenia who do not believe they are mentally ill. J Nerv Ment Dis. 2001; 189(3):146-53. DOI: 10.1097/00005053-200103000-00002. View

Segal S, Bola J, Watson M . Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services. Psychiatr Serv. 1996; 47(3):282-6. PMC: 7306413. DOI: 10.1176/ps.47.3.282. View

10.

Stange K, Zyzanski S, Smith T, Kelly R, Langa D, Flocke S . How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits. Med Care. 1998; 36(6):851-67. DOI: 10.1097/00005650-199806000-00009. View

11.

Salzer M, Nixon C, Schut L, Karver M, Bickman L . Validating quality indicators. Quality as relationship between structure, process, and outcome. Eval Rev. 1997; 21(3):292-309. DOI: 10.1177/0193841X9702100302. View

12.

Zhu K, McKnight B, Stergachis A, Daling J, Levine R . Comparison of self-report data and medical records data: results from a case-control study on prostate cancer. Int J Epidemiol. 1999; 28(3):409-17. DOI: 10.1093/ije/28.3.409. View

13.

Westbrook J, McIntosh J, Rushworth R, Berry G, Duggan J . Agreement between medical record data and patients' accounts of their medical history and treatment for dyspepsia. J Clin Epidemiol. 1998; 51(3):237-44. DOI: 10.1016/s0895-4356(97)00281-3. View

14.

Noordsy D, Torrey W, Mead S, Brunette M, Potenza D, Copeland M . Recovery-oriented psychopharmacology: redefining the goals of antipsychotic treatment. J Clin Psychiatry. 2000; 61 Suppl 3:22-9. View

15.

Mullan E, Katona P, DAth P, Katona C . Screening, detection and management of depression in elderly primary care attenders. II: Detection and fitness for treatment: a case record study. Fam Pract. 1994; 11(3):267-70. DOI: 10.1093/fampra/11.3.267. View

16.

Lehman A . Quality of care in mental health: the case of schizophrenia. Health Aff (Millwood). 1999; 18(5):52-65. DOI: 10.1377/hlthaff.18.5.52. View

17.

Day J, Wood G, Dewey M, Bentall R . A self-rating scale for measuring neuroleptic side-effects. Validation in a group of schizophrenic patients. Br J Psychiatry. 1995; 166(5):650-3. DOI: 10.1192/bjp.166.5.650. View

18.

Jeste D, GILBERT P, McAdams L, Harris M . Considering neuroleptic maintenance and taper on a continuum. Need for individual rather than dogmatic approach. Arch Gen Psychiatry. 1995; 52(3):209-12. DOI: 10.1001/archpsyc.1995.03950150041008. View

19.

Yager J, Linn L . Physician-patient agreement about depression: notation in medical records. Gen Hosp Psychiatry. 1981; 3(4):271-6. DOI: 10.1016/0163-8343(81)90031-1. View

20.

McGlynn E, Norquist G, Wells K, Sullivan G, Liberman R . Quality-of-care research in mental health: responding to the challenge. Inquiry. 1988; 25(1):157-70. View