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Documentation of Psychosis Risk Screening in Same-Day Adolescent Behavioural Health Consultations
Julia A Plumb1,2, Kelsey A Johnson3, Cailin Ryrie1
1Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
Early Intervention in Psychiatry
|June 28, 2026
Summary
Implementing psychosis screening in electronic medical records did not significantly increase documentation. However, direct clinician inquiry about psychosis risk identified new concerns in some young patients, highlighting its importance for early detection.
Area of Science:
- Psychiatry
- Mental Health Services Research
- Digital Health
Background:
- Early detection of psychosis is crucial for improving patient outcomes in serious mental illness.
- Adolescent and young adult populations are key demographics for early intervention strategies.
Purpose of the Study:
- To assess the prevalence of psychosis and the documentation of screening in behavioral health consultations.
- To evaluate the impact of integrating psychosis screening items into electronic medical record (EMR) templates.
Main Methods:
- Psychosis screening questions were incorporated into an EMR template for same-day behavioral health consultations.
- A retrospective chart review was performed to analyze screening documentation and identify psychosis prevalence.
Main Results:
- Psychosis screening documentation was present in only 28% of consultations.
- Direct clinician inquiry about psychosis occurred in 14% of cases, identifying at least one risk item in 20% of those instances.
- This direct inquiry led to the initial identification of psychosis concerns in three patients.
Conclusions:
- Integrating screening tools into EMRs did not guarantee their use in most behavioral health consultations.
- Direct clinician inquiry regarding psychosis risk is associated with identifying previously unrecognized risk factors and symptoms.
- Targeted clinician engagement is vital for effective psychosis risk assessment in young people.
