Peer review as an aid to improving the completeness of psychiatric case notes

Abstract

Clinical auditing and the setting of goals for continuing education are often based on case note reviews. Deficiencies in the comprehensiveness of the recorded case history place some restrictions on the usefulness of such reviews as guides to continuing education programmes. In this study, attempts were made to improve the quality of the data in psychiatric case notes by peer discussion, and by altering the case note recording guidelines. After each educational intervention a further detailed audit of the subsequent case histories was performed. Significant differences emerged in a few subsections of the case notes, but overall there was little change. Possible explanations for these findings are discussed.

Clinical information in psychiatric practice: what do doctors know, what do they think is known and what do they record?

“…The case notes fell well short of satisfactorily recording the information seen as the 'bare clinical essentials'. The similarity between this finding and that oftwo previous studies using the same criteria (Mellsop et al 1985;Ellis et al 1987) confirmed that this methodology for auditing notes was reliable.…”

“…The scoring of all case notes and case histories was performed by GB to eliminate interrater variability. Consistency of coding with records examined in previous studies was established (Mellsop et al 1985;Ellis et al 1987).…”

Continuing Medical Education in Psychiatry

“…There is already a literature which demonstrates an ability to measure changes in skills, including psychiatric interview skills [39], completeness of case notes [40], counselling skills [41] and learning behaviour therapy skills [42]. There is also a literature referring to the designing of research which evaluates quality of care in chronic schizophrenia [43].…”

Are your casenotes perfect?

“…The process of audit should be relevant, objective, quantified, repeatable and able to effect appropriate change in organisation of the service and clinical practice (Shaw, 1989). A casenote study by Ellis et al (1987) concluded that for peer review to be effective not only do issues need to be discussed but also reinforced at a later date.…”