title: Introduction of a standardized report form improves the quality of mental status examination reports by psychiatry residents.
abstract: The quality of mental status examination (MSE) reports in consecutive admission notes by psychiatric residents was compared before and after the introduction of a structured, pre-printed MSE form that had been designed for teaching and quality of care purposes. We found the use of the form to be associated with a marked improvement in the quality of the reports; however, an important item not on the form was less likely to be recorded than with an unstructured record of the MSE. We conclude that the use of structured MSE forms leads to a significant improvement in the comprehensiveness of MSE records. We therefore recommend that some version of a comprehensive, structured MSE form be adopted for use on adult inpatient psychiatry units where residents are being trained.
authors.affiliation: Department of Psychiatry, University of North Carolina, Campus Box 7160, Chapel Hill, NC, 27599-7160, USA.
authors.forename: R G
authors.initials: RG
authors.lastname: Ruegg
authors.forename: D
authors.initials: D
authors.lastname: Ekstrom
authors.forename: D L
authors.initials: DL
authors.lastname: Evans
authors.forename: R N
authors.initials: RN
authors.lastname: Golden