Quality and use of trauma histories obtained from psychiatric outpatients: a ten-year follow-up.
OBJECTIVE
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.


METHODS
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.


RESULTS
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%).


CONCLUSIONS
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.
Posner
Jonathan
J
Department of Psychiatry, Columbia College of Physicians and Surgeons, USA. jonathaneposner@gmail.com
Eilenberg
Julia
J
Friedman
Jill Harkavy
JH
Fullilove
Mindy J
MJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004282:Documentation / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000592:standards*; D001523:Mental Disorders / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D008875:Middle Aged; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology* / Q000523:psychology*; D011795:Surveys and Questionnaires