Documenting diagnosis in child and adolescent mental healthcare: A content analysis of diagnostic statements in a psychiatric case register

TY - JOUR

T1 - Documenting diagnosis in child and adolescent mental healthcare

T2 - A content analysis of diagnostic statements in a psychiatric case register

AU - O'Connor, Cliodhna

AU - Downs, Johnny

AU - McNicholas, Fiona

AU - Cross, Lauren

AU - Shetty, Hitesh

PY - 2020/6

Y1 - 2020/6

N2 - Understanding clinical practice in relation to psychiatric diagnosis is important for identifying avenues for service improvement, developing clinically valid research methods and informing debate about prevailing diagnostic systems. Minimal research has explored psychiatric diagnostic practice by studying the diagnostic information present in clinical records. This study identifies, quantifies and descriptively analyses the range of contexts in which diagnostic terms appear in free-text child and adolescent clinical notes. Text segments containing a diagnostic term (N = 2993) were extracted from children's electronic health records and subjected to content analysis. Segments were coded as indicating: definite diagnostic confirmations (49.4%), qualified diagnostic confirmations (6.4%), diagnostic queries/assessment (16.9%), definite diagnostic exclusions (3.1%), qualified diagnostic exclusions (2.2%), diagnostic status of another person (13.5%), or clinically irrelevant text (8.6%). Qualitative content analysis explored the linguistic patterns characterising these contexts of use. Results are considered in terms of their implications for service delivery, sociological analyses of psychiatric diagnosis, and the opportunities and challenges posed by applications of natural language processing techniques to electronic health records.

AB - Understanding clinical practice in relation to psychiatric diagnosis is important for identifying avenues for service improvement, developing clinically valid research methods and informing debate about prevailing diagnostic systems. Minimal research has explored psychiatric diagnostic practice by studying the diagnostic information present in clinical records. This study identifies, quantifies and descriptively analyses the range of contexts in which diagnostic terms appear in free-text child and adolescent clinical notes. Text segments containing a diagnostic term (N = 2993) were extracted from children's electronic health records and subjected to content analysis. Segments were coded as indicating: definite diagnostic confirmations (49.4%), qualified diagnostic confirmations (6.4%), diagnostic queries/assessment (16.9%), definite diagnostic exclusions (3.1%), qualified diagnostic exclusions (2.2%), diagnostic status of another person (13.5%), or clinically irrelevant text (8.6%). Qualitative content analysis explored the linguistic patterns characterising these contexts of use. Results are considered in terms of their implications for service delivery, sociological analyses of psychiatric diagnosis, and the opportunities and challenges posed by applications of natural language processing techniques to electronic health records.

KW - Child and adolescent mental healthcare

KW - Content analysis

KW - Diagnosis

KW - Electronic health records

UR - https://www.scopus.com/pages/publications/85082132591

U2 - 10.1016/j.childyouth.2020.104948

DO - 10.1016/j.childyouth.2020.104948

M3 - Article

AN - SCOPUS:85082132591

SN - 0190-7409

VL - 113

JO - Children and Youth Services Review

JF - Children and Youth Services Review

M1 - 104948

ER -