The patient's voice and the writer's role in mental health records

Over recent decades, formal requirements for medical records have been strengthened, for example through patients' rights of access. However, clinical documentation in mental health services has been criticised for becoming increasingly juridified and for failing to recognise patients as whole persons. The aim of this study was to conduct an exploratory investigation of current record-writing practices in mental health care.

We reviewed ten medical records from patients discharged from the Adult Inpatient Mental Health Unit at the Clinic for Mental Health and Substance Use Disorder, Oslo, who had at least one previous inpatient admission. The material comprised more than 5500 pages in total. A multidisciplinary research group, consisting of a literary scholar and healthcare personnel, analysed clinicians' notes, observational notes from ward staff recorded during admission, and outpatient records.

The records contained overwhelming volumes of text, with extensive verbatim repetition resulting from copy-and-paste practices, which at times obscured inconsistencies and contradictions. New information could appear suddenly and disappear again without reflection. The texts often displayed an inherent unreliability, with contradictory statements appearing side by side. Considerable emphasis was placed on diagnosis and discharge, while reflective discussion of clinical processes was often absent.

Authors of medical records must balance medical, legal and patient-centred requirements. Artificial intelligence is increasingly being introduced into clinical documentation, with the potential to fundamentally alter practice. However, there is also a need for authors to reclaim ownership of the medical record. In this study, the patient record emerges as a document that often exposes the author's sense of powerlessness.