A review of the medical records of adolescent psychiatric inpatients in a general hospital.

The psychiatric medical records of adolescents admitted to a major county receiving hospital over a six-month period were reviewed to discover the patterns of care. While 92 patients were admitted, medical records for only 56 were available from the record room. The two most common diagnoses were schizophrenia and adjustment reaction of adolescence. Patients diagnosed as schizophrenic received a major tranquilizer both at admission and at discharge; their hospitalization averaged 38 days. About half of these diagnosed as having an adjustment reaction were given a major tranquilizer at admission and at discharge; their average hospitalization was 21 days. In his review of the charts, the author found that a great deal of the data necessary for the analysis either were unavailable or were presented in a way that prevented accurate or reliable interpretation. He offers several recommendations for improving documentation in medical records of adolescents.