Heavy general hospital case notes: a simple case-finding method for psychiatric problems

Abstract

Objectives: To identify whether a simple marker of nonpsychiatric health service contact (weight of general hospital case notes) is helpfulin identifying patients with evidence of psychiatric disorder in a medical and surgical population.

Method: Hospital case note review identifying evidence of past and current psychiatric disorder in patients with heavy, medium and low weight case notes. Responses to letters to general practitioners and review of local psychiatric hospital records were used to validate findings. Setting: A large general teaching hospital in the centre of Leeds, UK. Subjects: Random sample of 240 patients aged 16-65 attending general hospital medical or surgical teams as an inpatient or day patient between April 1, 1991 and March 31, 1992. Patients whose index admission was to the gynaecology or obstetrics unit were excluded. Main outcomes: Non-psychiatric service contact was measured by case note weight and thickness, lifetime admissions and number of consultants seen. Psychiatric disorder was identified using global judgements based on a standardised assessment of the case notes, and also general practitioner statements of current or past psychiatric disorder and record of contact with psychiatric services.

Results: In a detailed examination of 75 cases, 92% of patients with lightweight notes had solely physical factors to account for their presentations, compared to 88% in the middleweight group and 64% in the heavyweight group. Heavier case notes more often contained comments about psychiatric problems affecting the physical presentation (lightweight 8%; middleweight 20%; heavyweight 64%). Patients with heavy case notes more often had a history of contact with psychiatric services as confirmed by the GP or contact at local psychiatric hospitals (lightweight 28% middleweight 24% heavyweight 48%). Amongst the heaviest service users, patients with a psychiatric problem had seen a median of 12.0 lifetime consultants compared to 8.5 in those where a purely physical cause was present.

Conclusions: Patients who have heavy hospital case notes are more likely to have evidence of psychiatric disorder than those with lower levels of hospital contact and this is more likely to have an impact on their physical presentation and clinical course as judged by case note review using structured assessment criteria.