Abstract
Aims and methodTo assess the usefulness of the electronic patient record, we used the search engine Clinical Record Interactive Search (CRIS) to scan all acute admissions during 2008 for possible substance use disorders. In addition, screening interviews were undertaken with 75 in-patients, and documentation in their files was compared with results of screening interviews.ResultsOf 839 acute admissions during 2008, 47% of males and 29% of females had reference to a substance misuse problem in their file. Documentation was unsystematic and inconsistent and mostly occurred in progress notes rather than in structured questionnaires. Screening interviews and manual review of files of 75 current in-patients confirmed that substance use disorders were common, but poorly documented.Clinical implicationsThe study highlights the power of search engines in scanning electronic clinical records, but also identified the limitations of unsystematic documentation in research and practice. Mental health staff were reluctant to diagnose or rate severity of substance misuse problems.
Highlights
Files were scanned to determine whether a National Drug Treatment Monitoring System (NDTMS) record had been completed in the Electronic Patient Journey System (ePJS)
In order to make an estimate of the extent to which the documentation in the ePJS corresponded to alcohol and drug misuse as reported during interviews using structured assessment instruments, a clinical audit was undertaken in July 2011, on five of the six acute admission wards that had been used in the Clinical Record Interactive Search (CRIS) analysis
Psychiatric junior medical staff did identify a substantial number of patients with substance use disorders, but did not do so consistently, nor primarily by use of the structured tools available to them
Summary
During 2008, there were 839 patients admitted to the 6 wards. Table 1 shows the identification of possible substance misuse among the patients. Completion of HoNOS ratings is considered mandatory, but almost all patients, 833/839, had a HoNOS admission completed, in 90/833 records the field for ‘problem alcohol or drug use’ was left blank; in total, 743 had this field filled out, and 125 patients were rated three or four Most of these individuals had a current or prior diagnosis of substance use disorder. Of the 38 patients identified as being currently or previously on methadone, 33 had been identified independently of the free-text search Using these different approaches to identifying possible substance use disorders in psychiatric in-patients, 47% of males and 29% of females were classified as having possible substance use disorder. 44 of the 70 people admitted with a primary substance use disorder diagnosis had contact with addiction services. Male n Age, years: mean Contact with addiction services, n (%) Length of stay, days: mean Readmitted, % Homeless, n
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