Exploring the symptom dimensions as documented in case record of patients with first episode psychosis at the first interview in the early assessment service for young people with psychosis (EASY) clinic

Abstract

Objectives Severe mental illness is a debilitating condition affecting a wide range of functioning of an individual. Identification of signs and symptoms is part of clinical assessment which aids case formulation, making diagnosis, determine treatment planning and outcome. How the symptoms are documented in case record undoubtedly affect the decision and communication among mental health professionals, treatment protocol, potential outcome and prognosis.

This is the first study in Hong Kong mental health service to overview the symptom dimensions documented by clinicians in case records. Currently, there is no clinical practice guideline to guide clinicians on symptom documentation. This study attempts to explore the symptom dimensions as documented in the first interview records of people with first episode psychosis in EASY clinic in a local hospital. The result will serve as preliminary reference material or the development of an appropriate documentation guideline or audit in future. Method A retrospective review of case records was conducted to evaluate the symptom documentation by clinicians. All first interview notes of patients suffering from schizophrenia spectrum disorder who attended the EASY clinic in 2012 were included.90 case records were identified. The symptoms characteristics were recorded into a template and categorized with reference to the domains of psychopathology in DSM-5, SAPS and SANS. A total of 29 items of symptom characteristics and related clinical features were identified and measured with descriptive statistics. Results All symptom characteristics and clinical features were reported in percentage. It was found that majority of interview notes(62%)had documented a range of 22-26items out of 29 items(76-90%) of symptom characteristics and clinical features observed from case records. Clinicians had demonstrated high proficiency in documenting a comprehensive range of psychiatric symptoms. Conclusion This paper aims to increase the awareness of clinicians on continuous evaluation of current practice on symptom documentation; to identify good practice or area for improvement; and initiate the development of standardized documentation guideline to guide future symptom documentation practice for betterment of quality patient care and service planning for people with first episode psychosis.