A systematic record of information collected during the processof
diagnosis and care is essential to document understandingof the patient's
mental, physical and social condition andthe clinical service provided
(Fig. 10.1).
Clinical charts are basic informational tools for all membersof the
clinical team. Charts should be kept in a secure andconfidential location and
should be accessible through an orderlyprocess to authorised clinical
personnel. In some settings,clinical charts may be electronically
available.
A chart should include narrative statements (using the patient'sown words
whenever possible) in all sections of the assessmentand care process. An
effort should be made to ensure legibilityof these statements. Occasionally,
a chart may include, inits relevant sections, structured or semi-structured
componentsto ensure that important information is covered in an effective
way.
The clinical chart should begin with a record of basic identifying
information, including the patient's name, address, telephonenumber, date of
birth, gender, ethnicity, religion, education,marital status, employment
status, insurance coverage (if relevant)and next of kin.
The results of a clinical diagnostic assessment and its linkageto care
should be recorded in narrative form under standardheadings, such as the
following:
The history of psychiatric and general medical illness shouldbe recorded,
as far as possible in chronological sequence,noting significant events, ages
and dates.
A family history of mental and general medical disorders andtreatment
should be collected for all known first- and second-degreerelatives,
including children, on both sides of the family.Personal, developmental and
social history should be recordedchronologically. In addition to narrative
statements, key milestonesand critical events may be recorded in a structural
manner.
The record of the symptom and mental state examination shouldcover all
important areas of mental activity and behaviour(e.g. appearance, overt
behaviour, mood and affect, speechand thought process, thought content,
perception, sensoriumor alertness, memory, judgement and insight). In every
case,personalised descriptions should be presented. Checklists mayalso be
used. Whenever possible, a physical examination shouldbe conducted.
A comprehensive diagnostic formulation that incorporates theinformation
obtained through the standardised and idiographicdiagnostic processes should
be recorded. The use of a systematicformat, as outlined in earlier parts, is
advisable.
The clinical chart should include a treatment plan, based onthe
comprehensive diagnostic formulation. It is advisable touse a systematic
treatment plan format linking clinical problemswith specific interventions,
such as that presented elsewherein this supplement
(IGDA Workgroup, WPA, 2003:
this suppl.).
IGDA Workgroup, WPA (2003) IGDA. 9: Linking
diagnosis to care treatment planning. British Journal of
Psychiatry, 182 (suppl. 45),
s58-s59.[Free Full Text] Mezzich, J. E. (ed.) (1986)Clinical
Care and Information Systems in Psychiatry. Washington, DC:
American Psychiatric Press. Sadock, B. J. (2000) Psychiatric report and
medical record. In Kaplan & Sadock's Comprehensive Textbook of
Psychiatry (7th edn) (eds B. J. Sadock & V. A. Sadock), pp.
665-677. Philadelphia, PA: Lippincott, Williams &
Wilkins. Sims, H. (2000) Clinical evaluation in
psychiatry. In Contemporary Psychiatry (vol.
I) (eds F. Henn et al). Berlin:
Springer. Soreff, S., Gulkin, T. & Pike, J. G. (1990)
The evolving clinical chart: how it reflects and influences psychiatric and
medical practice and the quality of care. Psychiatric Clinics of
North America, 13,
127-133.[Medline] Vidal, G. & Alarcón, R. D. (1986)Psiquiatría [Psychiatry]. Buenos Aires:
Panamericana.