INTRODUCTION: The aim of the study was to assess the quality of the clinical records of the patients who are seen in public hospitals in Madrid after a suicide attempt in a blind observation.
METHODS: Observational, descriptive cross-sectional study conducted at four general public hospitals in Madrid (Spain). Analyses of the presence of seven indicators of information quality (previous psychiatric treatment, recent suicidal ideation, recent suicide planning behaviour, medical lethality of suicide attempt, previous suicide attempts, attitude towards the attempt, and social or family support) in 993 clinical records of 907 patients (64.5% women), ages ranging from 6 to 92 years (mean 37.1±15), admitted to hospital after a suicide attempt or who committed an attempt whilst in hospital.
RESULTS: Of patients who attempted suicide, 94.9% received a psychosocial assessment. All seven indicators were documented in 22.5% of the records, whilst 23.6% recorded four or less than four indicators. Previous suicide attempts and medical lethality of current attempt were the indicators most often missed in the records. The study found no difference between the records of men and women (z=0.296; p=0.767, two tailed Mann-Whitney U test), although clinical records of patients discharged after an emergency unit intervention were more incomplete than the ones from hospitalised patients (z=2.731; p=0.006), and clinical records of repeaters were also more incomplete than the ones from non-repeaters (z=3.511; p<0.001).
CONCLUSIONS: Clinical records of patients who have attempted suicide are not complete. The use of semi-structured screening instruments may improve the evaluation of patients who have self- harmed.
Bibliographical noteCopyright © 2010 Sociedad Española de Psiquiatría and Sociedad Española de Psiquiatría Biológica. Published by Elsevier Espana. All rights reserved.
- deliberate self-harm
- emergency services