The purpose of this article is to share with the readers results of eight years of experience reviewing psychiatric charts in a general hospital. Included are background information, the process utilized, common charting errors, difficulties encountered, approaches in problem solving, and conclusions.
In the early 1970s it was the general consensus of the members of the Psychiatry Department at Hartford Hospital that future chart reviewing would probably be utilized by third party payers as a means of assessing indication for and quality of care rendered. As a result, members of the department established standards for adequate chart documentation and chart review process. The purpose of this was to demonstrate the ability to regulate the attending physician's charting and thus prevent an outside agency from imposing standards and a review system. This decision was not motivated solely out of concern, but also from a desire to improve the quality of documentation in patients' records without just engaging in a record review ritual. Initial hesitation stemmed from the feeling that high quality psychiatric care already was being rendered at the hospital and there was no indication in the literature that there was a direct correlation between well-documented charts and quality of patient care.
The Chairman of Hartford Hospital's Psychiatry Department asked two staff members to develop a method to measure the quality of documentation of clinical work. During the course of this study they distributed a questionnaire regarding this project to all members of the Department, The response was supportive in all respects except for rejection of any plan Io audit records while the patient was still in the hospital. A 12point questionnaire (Table 1) was developed.
The first meeting of the Chart Review Committee took place in 1974, Five members of the Psychiatry Department were assigned to this Committee, including the Department Chairman as well as the Director of the Inpatient Psychiatric Service. Between six and ten randomly selected records of discharged patients were reviewed weekly. This resulted in about 50% of all inpatient psychiatric records being reviewed. Thus, every attending psychiatrist's r ecord -keep in g ability was assessed on a regular basis. In the process each record is reviewed and then evaluated with a check or a zero for each of the 12 points on the assessment form by a committee member. The form is then folded, so that a second rater can evaluate and rate the chart without being influenced by the first rater. A third rater (inter-rater) opens the evaluation form, reviews the records and makes the final decision involving discrepancies between the first two raters. During each meeting every committee member has a chance to evaluate charts as one of the first two raters and as an inter-rater. After allcharts have been reviewed and rated, the member who first evaluated the chart presents the overall findings to the entire committee. If indicated, explanatory notes are made at the bottom of the evaluation form. A typed copy of each form is then sent to the attending psychiatrist, so that he/she can see how a committee of peers has assessed the psychiatrist's completeness of documentation. It is emphasized that the committee's task is assessment of documentation, not the assessment of the quality of care. It is known by each department member that the assessment sheets will never be released to anyone and that this policy was reviewed and endorsed by the hospital's legal counsel prior to initiating the committee's formation. All copies of completed evaluation forms are kept for one year in order to make tabulations which reflect the overall quality of chart documentation from year to year. The forms are then destroyed.
DEPARTMENT OF PSYCHIATRY-CHART REVIEW COMMITTEE
New members are rotated onto the committee on a regular basis. This has resulted in fresh input, increased opportunity for learning between committee members and improved documenting by the new committee member. The rotation offsets the predictable resistance, anger, and suspiciousness experienced by the staff. Over the past eight years IS different department members have served on the committee. This has resulted in a relatively broad spectrum of input with surprisingly little variation in the evaluation of the charts. The multiple membership will probably prevent the committee from becoming myopic in its functioning and allow each department member to think about how his or her charting can be improved, while monitoring the overall quality of others.
COMMONLY FOUND CHARTING ERRORS
Initially, it was noted that recurring charting errors were primarily due to the psychiatrist's omission of information from the charts. The following is a list of the most common charting deficiencies.
1. Why was the patient admitted to the hospital?
* Chief complaint does not indicate what the patient has to say about this problem.
* Incomplete identifying information, eg, age, sex, marital status, children, occupation, etc.
* No clear explanation of the presenting problem.
* No indication of precipitating factors), if any.
* Incomplete description of symptoms.
* No description of treatment utilized before hospitalization, eg, medications, dosages and results.
2. What has happened in the past that may contribute to the need for medical care?
* Skimpy past histories, with no reference to: previous mental health (eg, prior treatment and hospitalizations); family history of mental and /or physical illness; relationship with family; health problems; sexual conflicts; religious conflicts; occupational problems; legal problems; educational background; alcohol problem; drug problem; military problems; social adaptation; current adjustment, eg, relationship with wife, children and peers.
3. Is there a record of an adequate physical and mental status examination?
* Incomplete physical examinations, eg, charts without blood pressures recorded.
* Streamlined recording of mental status examination, eg, describing a patient as delusional without an example; indicating signs of organicity without documentation of substantiating findings; case discussions.
* Incomplete entries on mental status inventory examination form.
4. Is the admitting diagnosis complete and coded correctly and is it appropriate?
* Non-DSM diagnoses used.
* Inappropriate simultaneous use of diagnoses, eg, two neurotic or two psychotic or a neurotic and a psychotic diagnosis together.
* No coding of diagnoses.
* No inclusion of physical illnesses.
5. Is there evidence that treatment is reasonable?
* Treatment not appropriate to admission diagnosis, eg, if a neurotic is being treated with phenothiazine with no explanation.
6. Do progress notes document the effect or any change in treatment?
* Insufficient progress notes.
* Skimpy notes (no mention of all drugs utilized and dosages, why drugs were changed, progress of symptom picture, work-up in progress, diagnostic impression change, etc.)
* Medical illness treatment and laboratory results not included in follow-up notes.
* The amount of recorded psychodynamics and other personal data varies greatly from one attending physician to another.
* Illegible handwriting.
7. Is the quality of therapy appropriate in such matters as length of stay and selection of treatment?
* Rarely a problem in this area.
8. Does the chart furnish nursing personnel with adequate information and instructions for optimal care?
* Often the nursing advisory sheet is left blank.
9. Is there record of consultation for conditions which are outside the expertise of the psychiatric physician?
* Often no followup on abnormal laboratory and physical findings (it is the responsibility of the attending physician to see that his consultants follow up abnormal physical and laboratory findings as well as documenting findings and conclusions).
* Absence of psychological testing request when questionable diagnosis and absence of a statement when verbal results obtained from psychologist (as often complete report is not in chart until after discharge).
10. Are there appropriate plans for discharge?
* No mention of who will follow the patient postdischarge.
* No mention of medication and/or dosage prescribed on discharge (many on the committee feel that the number of pills prescribed should also be documented - especially in the case of suicidal patients).
* No mention of followup for medical/ surgical problems.
11. Does the discharge summary capture the essentials of the course in hospital?
* Summary does not tie case together.
* At times laboratory findings are described as normal when they are not.
* Inclusion of too much nonessential explicit material, especially in sexual area.
12. Is the discharge diagnosis complete and logical in view of the admitting diagnosis and course in hospital?
* Often no explanation of difference in discharge !diagnosis from the admitting diagnosis.
* No coding of psychiatric diagnosis.
As a result of this process quality of charting has improved greatly as reflected by the decreased incidence of charting errors (Table 2).
On the rare occasion when an attending physician's documentation of material has been consistently deficient, he/ she has been asked to join the Committee for a number of meetings. This has resulted in a rapid improvement in the completeness of the charting of these physicians, indicating that the committee's task has an effective teaching-learning yield.
This has been facilitated by the distribution of a summary of the most commonly noted errors in documentation to attending physicians at department meetings. Also, in order to correct areas of deficiency evident from reviewing of charts, other medical specialists have been invited to speak at department meetings. Issues discussed have included the interaction of antihypertensive and psychopharmacologic medications, neuroendocrinology, aspects of biochemistry and updates in cardiology, immunology, laboratory medicine, neuroradio logy, etc.
During the past eight years Hartford Hospital's Psychiatry Department Chart Review Committee has reviewed approximately 50% of the charts of discharged psychiatric inpatients by the use of a 12-point questionnaire. As a result the quality of documentation has improved dramatically with a possible associated improvement in the quality of psychiatric care. Associated benefits have included: an educational experience for Chart Committee members as well as for the department as a whole and a greater sense of security by department members in the event of a potential lawsuit. The department^ ability to use reliable methods to reach valid results has enhanced its status among other medical specialties, which have welcomed this advance within the general hospital.
EIGHT-YEAR OVERVIEW OF CHARTING DEFICIENCIES
1. Edelstein MG: Psychiatric peer review: A working model. Hasp Community Psychiatry 1976; 27(9): 656-65 9.
2. Kirstein L, Weissman MM: Utilization review of treatment for suicide atiempters: Chart review as patient care evaluation. Am J Psvchiairv 1975; 132:851-855.
3. Morrison SD: Retrospective audit; Depressive neurosis. Am J Psvchiairv 1977; 134:299-301.
DEPARTMENT OF PSYCHIATRY-CHART REVIEW COMMITTEE
EIGHT-YEAR OVERVIEW OF CHARTING DEFICIENCIES