Literature DB >> 24026375

Lost in documentation: a study of case-formulation documentation in letters after outpatient assessment.

Mohammed Juma Abbas, Lekshmi Premkumar, Amin Goodarzi, Ruth Walton.   

Abstract

OBJECTIVE: The authors sought to find out how frequently case-formulation is documented by psychiatrists after initial assessment in an outpatient clinic.
METHOD: Assessment letters for 150 new referrals/new referrals to a psychiatric clinic in Rotherham, U.K. were examined for the presence or absence of a case-formulation, as well as the different sections of the psychiatric history.
RESULTS: A group of 150 assessment letters were selected and examined. An overwhelming majority (94%) of letters did not include any case-formulation; this finding was not affected by the grade of the doctor.
CONCLUSIONS: Although case-formulation is considered an important skill by various training bodies, it seems that this is rarely translated into daily clinical practice. The authors discuss the possible reasons for this deficiency and discuss potential solutions.

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Mesh:

Year:  2013        PMID: 24026375     DOI: 10.1176/appi.ap.12060114

Source DB:  PubMed          Journal:  Acad Psychiatry        ISSN: 1042-9670


  1 in total

1.  A quantitative study on completeness rate of documentation in psychiatric medical records.

Authors:  Zahra Ebnehoseini; Hediye Khorasani; Fatemeh Moharari; Ali Reza Ebrahimi; Masoumeh Boroujerdi; Fatemeh Jamei; Mohammad Reza Mehri; Hamed Tabesh
Journal:  Indian J Psychiatry       Date:  2022-03-24       Impact factor: 2.983

  1 in total

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