Improving Psychiatric History-Taking Documentation: A Quality Improvement Audit and Re-Audit

Accurate psychiatric history taking is fundamental to diagnosis, formulation, treatment planning, and patient safety. This comparative audit evaluated the impact of training interventions on the completeness of psychiatric history documentation, compared outcomes across two audit cycles, and identified ongoing documentation deficits.

A clinical audit and re-audit were carried out in a community mental health service. The first audit cycle took place in July 2025 and the second in December 2025. In each cycle, 10 first-assessment psychiatric records of newly referred patients were reviewed. Each record was assessed according to the psychiatric history-taking domains described in Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Results: The re-audit showed improvements in several documentation domains. Personal history and social history increased from 30% and 50% in cycle 1 to 100% in cycle 2, while past psychiatric history improved from 80% to 100%. Presenting complaint and history of presenting illness remained stable at 100% and 90%, respectively. Mental state examination increased from 70% to 90%, and legal/forensic history improved from 40% to 50%. Identifying information and risk assessment remained unchanged at 80% and 80%, respectively. Some areas showed little improvement, with formulation increasing only slightly from 0% to 10% and alcohol history rising from 20% to 30%. Documentation in essential areas declined, with current medications falling from 30% to 10% and collateral history dropping from 70% to 20%.

Training helped improve the documentation of psychiatric history, but some areas remained incomplete. Ongoing supervision, experiential learning, and the use of structured templates are essential to sustaining improvements and ensuring that documentation remains comprehensive and accurate.