Setting

This audit is relevant to all specialties and can be conducted in both in-patient and out-patient departments.

Background

The documentation of a full and accurate history during a medical consultation is of utmost importance. There is evidence to suggest that 80% of diagnoses may be made on the basis of history alone (Hampton et al, 1975). In psychiatry, it could be argued that the history provides 100% of the diagnosis, if the mental state examination is included as part of the history. Case notes are referred to during legal proceedings; therefore, they need to be a complete and accurate record of consultations, decisions and actions (Osborn et al, 2005).

Standards

There are no specific standards from the Royal College of Psychiatrists regarding the content of psychiatric clinical notes. Therefore, a standard was constructed using the New Oxford Textbook of Psychiatry (a widely used and respected source). The authors outline the ‘perfect’ psychiatric history (Cooper & Oates, 2003). All aspects of the history should be documented completely (standard of 100%).

Method

Data collection

The medical notes of a random selection of patients were collected. Between 30 and 40 sets of notes was deemed adequate. Only first consultations were reviewed. A pro forma was developed for this audit that covered 11 main areas of the history (a total of 34 subheadings):

ᐅ patient identification (name, age, marital status, occupation, ethnic background, circumstances of referral)

ᐅ presenting complaint

ᐅ history of presenting complaint

ᐅ psychiatric history

ᐅ medical history

ᐅ family history (parents, siblings, medical history, psychiatric history)

ᐅ social history (financial, support structures, living arrangements, hobbies)

ᐅ personal history (birth, development, education, occupational history, relationships, children)

ᐅ forensic history

ᐅ premorbid personality (self-description, habits – drug and alcohol)

ᐅ mental state examination (appearance and behaviour, speech, thought form and content, mood and affect, perception, cognition and insight).

Data analysis

Each history was assigned a total score out of 34 (one point for each subheading) on the pro forma, which was expressed as a percentage. All the above should have been present for the standard to be met.