Quality and Use of Trauma Histories Obtained From Psychiatric Outpatients: A Ten-Year Follow-Up

Abstract

In 1996 Eilenberg and colleagues reviewed 180 charts and reported that trauma histories were poorly documented at a general psychiatric clinic. This study is a ten-year replication of that work. A total of 107 randomly selected charts from the same clinic were reviewed for assessment of trauma history. The quality of the assessments was rated. Fifty-six percent of charts contained a thorough description of trauma severity, compared with 15% in the initial study. Documentation of posttraumatic symptoms improved significantly in all categories but remained low. Documentation of diagnostic formulations and treatment plans for patients with a trauma history was thorough in a small proportion of charts (14%), as was found in the initial study (9%). Although some improvements were found in recording trauma histories, eliciting such a history did not lead to thorough documentation of posttraumatic symptoms or to inclusion of the history in the diagnostic formulation or treatment plan.