Development and Implementation of the ‘Clinical Assessment Summary’ for Providing Continuous Clinical Information

Abstract

<jats:p> Objective: To describe the development and implementation of a typed ‘continuous’ clinical summary, with a longitudinal formulation and modular episode-based summaries. </jats:p><jats:p> Methods: Outline of rationale for this form of summary and the implementation process. </jats:p><jats:p> Results: Despite identified technical and training difficulties, over 3000 clinical assessment summary documents have been created with successful implementation across a mental health service. </jats:p><jats:p> Conclusions: A typed continuous summary offers many advantages over a traditional discharge summary and can be implemented in routine clinical practice. </jats:p>

Formulation: A Proposal for a More Structured, Longitudinal Approach

“…Our belief is that the development of a detailed longitudinal formulation is of great heuristic benefit in the process of understanding and communicating relevant information about a patient in a targeted but comprehensive and timely manner, distilling a clinical case into an explanatory summary with a high “signal to noise” ratio. 4,12 This is accepted wisdom for psychiatrists, given our focus on the skill of formulation, and has been used to distinguish us from other disciplines. With increasing demands for service provision across many sites from multiple providers across disciplines, along with increasing demands for documentation, including structured outcomes measures, the development of a sophisticated longitudinal formulation is of great benefit in assisting continuity of care.…”

Historical Overview of a Psychiatric Clinical Information System: ‘Peninsula Pathways’

“…New modules and procedures, including for substance use, involuntary movements and cognition, were added in December 1999 to form the ‘Peninsula Pathways’ documentation suite. The clinical assessment summary (CAS) was trialled in June 2000 and implemented in July 2001 11 . A first‐presentation psychosis pathway was piloted from February 2003.…”

“…The clinical assessment summary (CAS) was trialled in June 2000 and implemented in July 2001. 11 A first-presentation psychosis pathway was piloted from February 2003.…”

Clinical Documentation

“…We promised and delivered on review and rapid initial revisions to address staff concerns. We linked the suite with the CAS, a simple Word template continuous clinical summary, 4 which gave tangible proof to staff of the potential benefits of systematic collection of high-quality clinical information. This also partially addressed the issue of which perspective in time is being adopted for a record.…”