A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT plus )

作者：Lobo Sarah E M; Rucker James; Kerr Madeleine; Gallo Fidel; Constable Giles; Hotopf Matthew; Stewart Robert; Broadbent Matthew; Baggaley Martin; Lovestone Simon; McGuffin Peter; Amarasinghe Myanthi; Newman Stuart; Schumann Gunter; Brittain Philip J^*

来源：International Journal of Medical Informatics, 2015, 84(9): 675-682.

DOI：10.1016/j.ijmedinf.2015.05.001

• Mental state examination
• Electronic health records
• OPCRIT
• Psychiatry Junior doctors Documentation
• National Health Service
• Semi-structured

Objectives: The mental state examination (MSE) provides crucial information for healthcare professionals in the assessment and treatment of psychiatric patients as well as potentially providing valuable data for mental health researchers accessing electronic health records (EHRs). We wished to establish if improvements could be achieved in the documenting of MSEs by junior doctors within a large United Kingdom mental health trust following the introduction of an EHR based semi-structured MSE assessment template (OPCRIT+).
Methods: First, three consultant psychiatrists using a modified version of the Physician Documentation Quality Instrument-9 (PDQI-9) blindly rated fifty MSEs written using OPCRIT+ and fifty normal MSEs written with no template. Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT+MSEs.
Results: PDQI-9 ratings indicated that the OPCRIT+MSEs were more 'Thorough', 'Organized', 'Useful' and 'Comprehensible' as well as being of an overall higher quality than the normal MSEs. The audit identified that the normal MSEs contained fewer mentions of the individual components of 'Thought content', 'Anxiety' and 'Cognition & Insight'.
Conclusions: These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs. Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.

• 出版日期2015-9