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Improving Psychiatric History-Taking Documentation: A Quality Improvement Audit and Re-Audit
1Psychiatry, St. Lukes Hospital, Kilkenny, IRL.
Cureus
|June 2, 2026
Summary
Psychiatric history documentation improved after training, but gaps remain. Ongoing supervision and structured templates are key for comprehensive and accurate patient records.
Area of Science:
- Psychiatry
- Clinical Auditing
- Medical Documentation
Background:
- Accurate psychiatric history taking is crucial for diagnosis, treatment, and patient safety.
- Clinical audits are essential for evaluating and improving healthcare practices.
- Gaps in documentation can impact patient care and safety.
Purpose of the Study:
- To evaluate the impact of training interventions on psychiatric history documentation completeness.
- To compare documentation outcomes between two audit cycles.
- To identify persistent deficits in psychiatric history documentation.
Main Methods:
- A comparative clinical audit and re-audit were conducted in a community mental health service.
- 10 first-assessment psychiatric records were reviewed in each of two cycles (July 2025 and December 2025).
- Records were assessed against domains from Kaplan and Sadock's Comprehensive Textbook of Psychiatry.
Main Results:
- Significant improvements were noted in personal history, social history, and past psychiatric history documentation.
- Mental state examination and legal/forensic history documentation also showed improvement.
- Areas like formulation and alcohol history saw minimal improvement, while current medications and collateral history declined.
Conclusions:
- Training interventions positively impacted psychiatric history documentation completeness.
- Certain areas, such as formulation and medication history, require further attention.
- Sustained improvement necessitates ongoing supervision, experiential learning, and structured documentation templates.
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