STUDY OBJECTIVES: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatric patients. DESIGN: Descriptive, retrospective chart review. SETTING: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. TYPE OF PARTICIPANTS: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented "medically clear" in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. CONCLUSION: Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement "medically clear" is inaccurate and should be replaced by a thorough discharge note.
STUDY OBJECTIVES: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatricpatients. DESIGN: Descriptive, retrospective chart review. SETTING: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. TYPE OF PARTICIPANTS: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented "medically clear" in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. CONCLUSION:Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement "medically clear" is inaccurate and should be replaced by a thorough discharge note.
Authors: Tony W Thrasher; Martha Rolli; Robert S Redwood; Michael J Peterson; John Schneider; Lisa Maurer; Michael D Repplinger Journal: WMJ Date: 2019-12
Authors: Brian J Yun; Shih-Chuan Chou; Justine M Nagurney; Benjamin A White; Curtis W Wittmann; Ali S Raja Journal: Am J Emerg Med Date: 2017-10-04 Impact factor: 2.469
Authors: Michael P Wilson; Kimberly Nordstrom; Eric L Anderson; Anthony T Ng; Leslie S Zun; Jennifer M Peltzer-Jones; Michael H Allen Journal: West J Emerg Med Date: 2017-05-01
Authors: Eric L Anderson; Kimberly Nordstrom; Michael P Wilson; Jennifer M Peltzer-Jones; Leslie Zun; Anthony Ng; Michael H Allen Journal: West J Emerg Med Date: 2017-01-19