Psychiatric case-note auditing

Objective: Maintenance of psychiatric case notes is an important tool both in terms of patient management and training. In order to look scientifically into this aspect a study was conducted aiming at auditing of psychiatric case notes with a view to observe the shortcomings and identify areas for its improvement. Design: An observational study. Place and Duration of Study: The psychiatric case notes were examined for auditing with the random selection of every second case note totaling to ten in each of the twenty private and public sector psychiatric setups in Karachi, through a period of three months. Subjects and Methods: A psychiatric case note auditing was done in 20 psychiatric setups from which a total of 200 case notes were examined with the help of a standard proforma. Results: It was noted that in both private and public sector psychiatric setups issues related to prognosis, other therapeutic details, involvement of GP and notes by the multidisciplinary team were missing and not recorded, although, follow-up visits and discharge plans were better documented in the private setups. Conclusion: It was concluded that psychiatric case-note auditing is important in terms of patient management and trainees' education.