The quality of clinical notes at a Psychiatric Hospital in Saudi Arabia
1Department of Family and Community Medicine (2330), King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. Tel. +966 (1) 252 0088 Ext. 2018. Fax. +966 (1) 252 0088 Ext. 3219.
Objective:
This study aims to display the quality of the clinical notes at Abha Psychiatric Hospital out-patient clinics.
Methods:
In this chart review study, a total of 380 charts were randomly collected, and reviewed for the clinical items that should be included in the psychiatric clinical notes. Each chart note quality was indicated as good, fair or poor based on means and standard deviations.
Results:
The quality of clinical notes was good in 16.3%, fair in 71.1% and poor in 12.6% of the total records. The most frequent clearly present items were medications (92.1%), and personal data (91.1%); while the most frequent clearly absent items were psychotherapy (90.8%), and functioning (80.8%).
Conclusion:
The quality of psychiatric clinical notes needs to be improved. Practical recommendations regarding this were stressed.
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