A quantitative study on completeness rate of documentation in psychiatric medical records

Abstract

Background: Mental disorders are one of the leading causes of illness and disability worldwide. According to the World Health Organization (WHO), one in four people in the world will be affected by mental or neurological disorders during their lifetime. Regular evaluation of mental health outcomes plays an important role in making decisions about timely treatment of the patient. Studies show that a medical record does not provide enough information about the diagnosis, current symptoms, psychiatric medications, and side effects of current medications and treatments for ongoing health care. In this study, the completeness of paper-based psychiatric records was investigated. Aim: The current study aimed to explore the completeness rate of paper-based psychiatric medical records (PMRs) and to investigate the factors effective on documentation status. Setting: The study was conducted in Ebnesina and Dr. Hejazi Psychiatric Hospital and Education Center. The case hospital is a psychiatric teaching hospital, which has 900 beds. Materials and Methods: The completeness rate of PMRs was determined using descriptive statistics. Fleiss’ Kappa agreement and effective factors on PMRs’ documentation status were assessed. Results: In total, 83.65% ( n = 312) of the PMRs had at least one documentation defect. A significantly higher level of documentation completeness rate between different psychiatric wards was observed. Conclusion: Based on our results, it is suggested to conduct regular evaluation and provide feedback to the health-care providers, and conduct training courses.