A Clinical Audit of Mental State Examination Documentation Among Psychiatric Residents in a Tertiary Care Hospital

Abstract

Introduction: Modern psychiatry uses Mental State Examination (MSE) as a tool for collecting data and assisting a psychiatrist in developing patient’s working psychiatric diagnosis. There are currently no national criteria on a definitive format of MSE, nor do the bulk of psychiatry training programs insist upon it. However, to ensure proper documentation of MSE results, following a structured format is needed, ensuring that all relevant components of the examination are covered. For this, we conducted this clinical audit regarding proper MSE documentation within the Psychiatry department of a tertiary care hospital. Methods: The study was conducted in the Department of Psychiatry, Civil Hospital Karachi between 15-02-2023 till 15- 04-2023 after approval by Head of Department. A standardized MSE format consisting of 11 parameters of psychiatric analysis was prepared according to British Medical Journal (BMJ) and Oxford University Press guidelines. The parameters incorporated appropriate date, time, and signature of the examining doctor, in addition to proper documentation of appearance, behavior, speech, mood and affect, suicidal and homicidal risk, thought process, perception, cognition (Orientation, attention, concentration, memory and abstract thinking), insight, judgement, and event notes/progress notes sections. The study was divided into two cycles. A retrospective analysis to detect the shortcomings of MSE documentation was done (sample size n=30), followed by a second cycle, in which a standardized MSE template was provided to all psychiatric residents to examine patients prospectively for the next 4 weeks. Data was analyzed using SPSS software to compare the improved changes in MSE documentation. Results: The result showed that all 11 parameters were recorded correctly, however certain sub-parameters were recorded poorly. The least recorded parameters were date of examination (53.3%), Physical stigmata (43.3%), psychomotor retardation (16.7%), and signs of Extrapyramidal symptoms (10.0%), speech assessment (46.7%), suicidal risk (20.0%), and homicidal risk (13.3%), perception assessment [Illusion (16.7%), depersonalization (13.3%), derealization (16.7%) and memory assessment. Documentation of event notes/progress notes was also recorded poorly (33.3%)]. There was an overall improvement in the documentation pattern of all the 11 parameters of MSE during the second audit cycle. The parameters and sub-parameters with an improvement included physical stigmata (66.7%), psychomotor retardation (76.7%), signs of Extrapyramidal symptoms (83.3%), speech assessment (90.0%), suicidal risk (83.3 %%), homicidal risk (83.3%), perception assessment [Illusion (86.7%), depersonalization (86.7%), derealization (80.0%)] and memory assessment. Patient’s name and registration number were perfectly recorded with a percentage of 100% in the first audit cycle, however it declined to 86.7% in the second cycle. There were also marginal improvements in documentation of date of examination and examining doctor’s name. Conclusion: The introduction of an MSE format and consultant supervision of records improved the standard of MSE recording as well as basic medico-legal requirements by psychiatric trainees