title: [Documentation of comorbid mental disorders in medical rehabilitation: an analysis of discharge reports].
abstract: OBJECTIVE
  Patients with chronic somatic -diseases often suffer from psychological distress and mental disorders, which remain unrecognized in somatic rehabilitation. The present -study aimed to investigate whether the implementation of a stepwise psychodiagnostic procedure improves the documentation of psychological distress and mental disorders as well as of the -related inpatient treatments and aftercare recommendations.
  
  
  METHODS
  Implementation of a stepwise psychodiagnostic procedure in 5 orthopaedic, cardiologic and oncologic inpatient rehabilitation clinics. The 4 steps comprised (1) screening, (2) in-depth psychodiagnostic assessment, (3) diagnosis and treatment, (4) documentation. Implementation efficacy in terms of a better documentation was evaluated by comparing the discharge reports of every fifth screening-positive and screening-negative patient (n=146) with historical discharge reports of the last 3 months preceding baseline assessment (n=161).
  
  
  RESULTS
  Mental disorders (26,0% vs. 21,7%), general psychological treatment (75,3% vs. 66,5%), specific psychological treatment (32,9% vs. 31,7%), as well as psychologically relevant aftercare recommendations (41,1% vs. 34,8%) were more frequently documented in the current post-implementation discharge reports compared to the historical discharge reports. A significant difference was found only for the documentation of general psychological treatment.
  
  
  CONCLUSIONS
  The results suggest that the implementation of a stepwise psychodiagnostic procedure improves the documentation of psychological distress and mental disorders as well as related inpatient treatments and aftercare recommendations. Continuous staff training and quality assurance relative to the discharge reports may contribute to further enhancing the documentation of psychological distress and mental disorders.
authors.affiliation: Abteilung für Rehabilitationspsychologie und Psychotherapie, Institut für Psychologie, Universität Freiburg, Freiburg, Germany. jeanette.jahed@psychologie.uni-freiburg.de
authors.forename: J
authors.initials: J
authors.lastname: Jahed
authors.forename: I
authors.initials: I
authors.lastname: Bitz
authors.forename: J
authors.initials: J
authors.lastname: Bengel
authors.forename: H
authors.initials: H
authors.lastname: Baumeister
mesh_terms: D015897:Comorbidity; D006233:Persons with Disabilities / Q000534:rehabilitation* / Q000706:statistics & numerical data*; D004282:Documentation / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005858:Germany / Q000453:epidemiology; D055991:Health Records, Personal; D006801:Humans; D015994:Incidence; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000453:epidemiology*; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D012046:Rehabilitation / Q000706:statistics & numerical data*; D012307:Risk Factors