A retrospective chart review of trauma‐related documentation in an Australian substance use treatment service

Abstract

Introduction: Trauma exposure among clients of substance use treatment services is almost universal and rates of trauma-related symptoms are correspondingly high.This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation of trauma-related comorbidities and their treatment in a substance use treatment setting.Methods: A retrospective chart review was conducted on a sample of 300 patient records in a public substance use treatment setting. Rates of documentation of trauma-related events, symptoms and treatment, along with variables influencing the documentation of these issues, were examined. Results: Trauma-related documentation was present in 45.3% of records. There were documented trauma-related symptoms in 15.3% of records, although treatment activities addressing trauma were only present in 2.3% of records. Being female (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.42, 4.69), having prior mental health treatment (OR 1.82, 95% CI 1.05, 1.12) and having more treatment sessions (OR 1.08, 95% CI = 1.05, 1.12) increased the odds of trauma-related documentation being present, while being in the first episode of treatment (OR 0.49, 95% CI = 0.28, 0.84) decreased the odds.Discussion and Conclusions: This study highlights significant under documentation of trauma-related comorbidities in substance-use treatment. There is limited evidence of consideration of trauma-related symptoms or diagnoses, and trauma-related comorbidities are rarely included in treatment planning activities. The lack of documented trauma-related information has important clinical and medico-legal implications for patients, and provides evidence to suggest a lack of integration of treatment for trauma-related disorders in substance use settings.