The validity of psychiatric case note records to assess treatment outcome: Comparison at admission and at discharge

This paper examines the validity of symptom information recorded at admission and at discharge in routine psychiatric case notes using two well-established instruments for criteria comparisons: the Present State Examination (PSE), a diagnostic tool which also yields severity score and the Comprehensive Psychopathological Rating Scale (CPRS), an instrument suitable to measure change. In a study that compared outcome and costs of day hospital and in-patient treatments, acute psychiatric patients were randomly assigned to these two services and interviewed at different points in time by means of two rating schedules, the PSE and the CPRS. The PSE and the CPRS were applied at admission independently from the admitting doctor who reported his/her findings to the case notes, and the CPRS was used again at two weeks and at 1, 2, 3, 6, and 12 months from admission. To study the validity of symptom recording in routine case notes, symptom information was abstracted from the case notes at admission and at discharge and compared with these PSE and CPRS ratings, providing paired observations derived from case notes and interviews. There is a tendency to under-reporting in case notes. Symptoms are not recorded systematically at discharge and prospective studies would seek to improve availability of data. However, case notes offer an economical approach to outcome measurement if information at admission can be linked to an assessment at discharge. The present study supports the validity of symptoms recorded in case notes for use in this and open possibility for replicability.