Abstract

OBJECTIVE--To devise a proforma for clinical documentation of psychiatric illness in an accident and emergency (A&E) department, since A&E senior house officers (SHOs) have little psychiatric experience before starting their jobs. METHODS--History taking and mental state examinations by 16 SHOs were compared before (n = 50) and after (n = 50) the introduction of the proforma. Comments on the proforma were provided by all participants on a questionnaire. RESULTS--There was an improvement in documentation with the use of the proforma (Mann-Whitney U test, P < 0.001). The senior house officers found the proforma useful and supported further development of this initiative. CONCLUSIONS--A standard form for documenting psychiatric history, designed according to local needs, is useful and should be available in A&E departments.