TY - JOUR
T1 - A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT+)
AU - Lobo, Sarah Elizabeth Margaret
AU - Rucker, James
AU - Kerr, Madeleine
AU - Gallo, Fidel
AU - Constable, Giles
AU - Hotopf, Matthew Hugo
AU - Stewart, Robert James
AU - Broadbent, Matthew
AU - Baggaley, Martin
AU - Lovestone, Simon H
AU - McGuffin, Peter
AU - Amarasinghe, Jithani Myanthi
AU - Newman, Stuart
AU - Schumann, Gunter
AU - Brittain, Philip
PY - 2015/9/1
Y1 - 2015/9/1
N2 - Objectives
The mental state examination (MSE) provides crucial information for healthcare professionals in the assessment and treatment of psychiatric patients as well as potentially providing valuable data for mental health researchers accessing electronic health records (EHRs). We wished to establish if improvements could be achieved in the documenting of MSEs by junior doctors within a large United Kingdom mental health trust following the introduction of an EHR based semi-structured MSE assessment template (OPCRIT+).
Methods
First, three consultant psychiatrists using a modified version of the Physician Documentation Quality Instrument-9 (PDQI-9) blindly rated fifty MSEs written using OPCRIT+ and fifty normal MSEs written with no template. Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT + MSEs.
Results
PDQI-9 ratings indicated that the OPCRIT + MSEs were more ‘Thorough’, ‘Organized’, ‘Useful’ and ‘Comprehensible’ as well as being of an overall higher quality than the normal MSEs. The audit identified that the normal MSEs contained fewer mentions of the individual components of ‘Thought content’, ‘Anxiety’ and ‘Cognition & Insight’.
Conclusions
These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs. Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.
AB - Objectives
The mental state examination (MSE) provides crucial information for healthcare professionals in the assessment and treatment of psychiatric patients as well as potentially providing valuable data for mental health researchers accessing electronic health records (EHRs). We wished to establish if improvements could be achieved in the documenting of MSEs by junior doctors within a large United Kingdom mental health trust following the introduction of an EHR based semi-structured MSE assessment template (OPCRIT+).
Methods
First, three consultant psychiatrists using a modified version of the Physician Documentation Quality Instrument-9 (PDQI-9) blindly rated fifty MSEs written using OPCRIT+ and fifty normal MSEs written with no template. Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT + MSEs.
Results
PDQI-9 ratings indicated that the OPCRIT + MSEs were more ‘Thorough’, ‘Organized’, ‘Useful’ and ‘Comprehensible’ as well as being of an overall higher quality than the normal MSEs. The audit identified that the normal MSEs contained fewer mentions of the individual components of ‘Thought content’, ‘Anxiety’ and ‘Cognition & Insight’.
Conclusions
These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs. Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.
UR - http://www.scopus.com/inward/record.url?scp=84946494773&partnerID=8YFLogxK
U2 - 10.1016/j.ijmedinf.2015.05.001
DO - 10.1016/j.ijmedinf.2015.05.001
M3 - Article
SN - 1386-5056
VL - 84
SP - 675
EP - 682
JO - International Journal of Medical Informatics
JF - International Journal of Medical Informatics
IS - 9
ER -