Data omitted from psychiatric consultation notes.

Abstract

To assess how often psychiatric consultants omit written data from their consultation notes, the authors reviewed 78 initial consultation notes written by second-year psychiatric residents. Data considered essential for an adequate psychiatric evaluation were typically omitted. Categories that were observed to have the highest frequencies of missing data included family history of psychiatric illness (60.3%), history of substance abuse (44.9%), marital status (37.2%), previous psychotropic drug use (35.9%), previous psychiatric treatment (26.9%), and patient history of psychiatric illness (24.4%). The frequencies of omissions were significantly (p less than .001, except for the last item, p less than .01) higher than those from the consultation notes written by a second cohort of psychiatric residents who used a worksheet that listed data categories. The authors' findings argue for the use of worksheets delineating data categories to ensure that clinicians write adequate consultation notes.