Abstract
Medical records are commonly used to measure quality of care. However, little is known about how accurately they reflect patients' clinical condition. Even less is understood about what influences the accuracy of provider's documentation and whether patient characteristics impact documentation habits. Discrepancies between symptoms and side effects evaluated by direct assessment and medical records were examined for 224 patients with schizophrenia at two public mental health clinics. Multivariate regression was used to study the relationship between patient, provider, and treatment characteristics and documentation accuracy. Overall, documentation of symptoms and side effects was frequently absent. Documentation varied substantially between clinics, and it was generally less likely for patients who were severely ill, black, or perceived as noncompliant. The accuracy and consistency of medical record documentation should be demonstrated before using it to evaluate care at public mental health clinics.
References
Lehman AF. Quality of care in mental health: the case of schizophrenia.Health Affairs. 1999;18:52–65.
Young AS, Sullivan G, Burnam MA, et al. Measuring the quality of outpatient treatment for schizophrenia.Archives of General Psychiatry. 1998;55:611–617.
McGlynn EA, Norquist GS, Wells KB, et al. Quality-of-care research in mental health: responding to the challenge.Inquiry. 1988;25:157–170.
Salzer MS, Nixon CT, Schut LJA, et al. Validating quality indicators: quality as relationship between structure, process, and outcome.Evaluation Review. 1997;21:292–309.
Young AS, Grusky O, Jordan D, et al. Routine outcome monitoring in a public mental health system: the impact of patients who leave care.Psychiatric Services. 2000;51:85–91.
Zisook S, Byrd D, Kuck J, et al. Command hallucinations in outpatients with schizophrenia.Journal of Clinical Psychiatry. 1995;56:462–465.
Mullan E, Katona P, D'Ath P, et al. Screening, detection and management of depression in elderly primary care attenders. II: detection and fitness for treatment: a case record study.Family Practice. 1994;11:267–270.
Nowels A. A review of the medical records of adolescent psychiatric inpatients in a general hospital.Hospital and Community Psychiatry. 1977;28:903–906.
Yager J, Linn LS. Physician-patient agreement about depression: notation in medical records.General Hospital Psychiatry. 1981;3:271–276.
Westbrook JI, McIntosh JH, Rushworth RL, et al. Agreement between medical record data and patients' accounts of their medical history and treatment for dyspepsia.Journal of Clinical Epidemiology. 1998;51:237–244.
Zhu K, McKnight B, Stergachis A, et al. Comparison of self-report data and medical records data: results from a case-control study on prostate cancer.International Journal of Epidemiology. 1999;28:409–417.
Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits.Medical Care. 1998;36:851–867.
First MB, Spitzer RL, Gibbon M, et al.Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Patient Edition, Version 2.0. New York: New York State Psychiatric Institute; 1995.
American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
Ventura J, Lukoff D, Nuechterlein KH, et al. Brief Psychiatric Rating Scale (BPRS) expanded version (4.0): scales, anchor points and administration manual.International Journal of Methods in Psychiatric Research. 1993;3:227–243.
Jones SH, Thornicroft G, Coffey M, et al. A brief mental health outcome scale—reliability and validity of the Global Assessment of Functioning (GAF).British Journal of Psychiatry. 1995;166:654–659.
Barnes TR. A rating scale for drug-induced akathisia.British Journal of Psychiatry. 1989;154:672–676.
Day JC, Wood G, Dewey M, et al. A self-rating scale for measuring neuroleptic side-effects. Validation in a group of schizophrenic patients.British Journal of Psychiatry. 1995;166:650–653.
Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale.Hospital and Community Psychiatry. 1988;39:1172–1177.
Miklowitz DJ, Goldstein MJ, Nuechterlein KH, et al. Expressed emotion, affective style, lithium compliance, and relapse in recent onset mania.Psychopharmacology Bulletin. 1986;22:628–632.
Pyne JM, Bean D, Sullivan G. Characteristics of persons with schizophrenia who do not believe they are mentally ill.Journal of Nervous and Mental Disease. 2001;189:146–153.
Wallace CJ, Liberman RP, MacKain SJ, et al. Effectiveness and replicability of modules for teaching social and instrumental skills to the severely mentally ill.American Journal of Psychiatry. 1992;149:654–658.
Young AS, Sullivan G, Duan N. Patient, provider, and treatment factors associated with poor quality care for schizophrenia.Mental Health Services Research. 1999;1:201–211.
Noordsy DL, Torrey WC, Mead S, et al. Recovery-oriented psychopharmacology: redefining the goals of antipsychotic treatment.Journal of Clinical Psychiatry. 2000;61(suppl 3):22–29.
Jeste DV, Gilbert PL, McAdams LA, et al. Considering neuroleptic maintenance and taper on a continuum. Need for individual rather than dogmatic approach.Archives of General Psychiatry. 1995;52:209–212.
Dye N, DiMatteo M. Enhancing cooperation with the medical regimen. In: Lipkin M, Putnam SM, Lazare A, eds.The Medical Interview: Clinical Care, Education, Research. New York: Springer-Verlag; 1995.
Segal SP, Bola JR, Watson MA. Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services.Psychiatric Services. 1996;47:282–286.
Baker JG, Shanfield SB, Schnee S. Using quality improvement teams to improve documentation in records at a community mental health center.Psychiatric Services. 2000;51:239–242.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cradock, J., Young, A.S. & Sullivan, G. The accuracy of medical record documentation in schizophrenia. The Journal of Behavioral Health Services & Research 28, 456–465 (2001). https://doi.org/10.1007/BF02287775
Issue Date:
DOI: https://doi.org/10.1007/BF02287775