title: A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT+).
abstract: OBJECTIVE
  The mental state examination (MSE) provides crucial information for healthcare professionals in the assessment and treatment of psychiatric patients as well as potentially providing valuable data for mental health researchers accessing electronic health records (EHRs). We wished to establish if improvements could be achieved in the documenting of MSEs by junior doctors within a large United Kingdom mental health trust following the introduction of an EHR based semi-structured MSE assessment template (OPCRIT+).
  
  
  METHODS
  First, three consultant psychiatrists using a modified version of the Physician Documentation Quality Instrument-9 (PDQI-9) blindly rated fifty MSEs written using OPCRIT+ and fifty normal MSEs written with no template. Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT+MSEs.
  
  
  RESULTS
  PDQI-9 ratings indicated that the OPCRIT+MSEs were more 'Thorough', 'Organized', 'Useful' and 'Comprehensible' as well as being of an overall higher quality than the normal MSEs. The audit identified that the normal MSEs contained fewer mentions of the individual components of 'Thought content', 'Anxiety' and 'Cognition & Insight'.
  
  
  CONCLUSIONS
  These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs. Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Sarah E M
authors.initials: SE
authors.lastname: Lobo
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Rucker
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Madeleine
authors.initials: M
authors.lastname: Kerr
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Fidel
authors.initials: F
authors.lastname: Gallo
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Giles
authors.initials: G
authors.lastname: Constable
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hotopf
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Robert
authors.initials: R
authors.lastname: Stewart
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Broadbent
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Baggaley
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Lovestone
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: McGuffin
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Myanthi
authors.initials: M
authors.lastname: Amarasinghe
authors.affiliation: Medical Research Council Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.
authors.forename: Stuart
authors.initials: S
authors.lastname: Newman
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.
authors.forename: Gunter
authors.initials: G
authors.lastname: Schumann
authors.affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom. Electronic address: Philip.Brittain@kcl.ac.uk.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Brittain
mesh_terms: D002983:Clinical Competence; D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008505:Medical Staff, Hospital; D001523:Mental Disorders / Q000145:classification / Q000175:diagnosis*; D015588:Observer Variation; D011569:Psychiatric Status Rating Scales; D011570:Psychiatry / Q000592:standards*; D006113:United Kingdom
keywords: Audit; Documentation; Electronic health records; Junior doctors; Mental state examination; National Health Service; OPCRIT+; Psychiatry; Semi-structured