Do psychiatric case notes contain enough information to assess the treatment outcome?

This paper presents a study assessing the availability of information within psychiatric hospital case notes. It was made a retrospective review of the case notes of patients admitted to three different psychiatric settings in London - a day hospital, a psychiatric ward in a general hospital, and an intensive care ward in a psychiatric hospital. Apart from social, demographic and administrative information, data on symptoms, behaviour and social condition were also collected using special check lists and a reliability study was carried out. Only 1% of the patients did not have the mental state examination reported at admission. It was found an overall 'response rate' of 83% for demographic and clinical variables, 57% for symptoms, 8% for behaviour items, and 32% for social items. Symptoms 'reported as present' on admission could be linked to information on discharge for 55% of symptoms. Inter-rater reliability for this study attained moderate to substantial levels. Case notes offer a cheap and potential source of data to measure the outcome of routine psychiatric treatment in terms of collecting baseline symptom information at admission, but more attention is needed to recording outcome assessment at discharge.