Am J Psychiatry 1982; 139:1154-1157
Copyright © 1982 by American Psychiatric Association
Psychiatric records: variations based on discipline and patient characteristics, with implications for quality of care
BB Perlman, AH Schwartz, M Paris, JC Thornton, H Smith and R Weber
In this study of the delivery of outpatient psychiatric care to Medicaid
patients at all 29 free-standing psychiatric clinics and at six hospital
clinics in New York City, the authors found that nonphysician mental health
workers provided much direct patient care: diagnosis and identifying data,
necessary for reimbursement, were always included in records whereas mental
status and medical history were poorly documented; and nonphysicians in
hospitals generally surpassed physicians in the latter two areas. An
additional observation was that attitudes of mental health workers toward
certain diagnostic and ethnic groups may be inferred from the selective
completeness of their psychiatric record keeping.
