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Psychiatr Serv. 2008 Mar;59(3):318-21. doi: 10.1176/appi.ps.59.3.318.

Quality and use of trauma histories obtained from psychiatric outpatients: a ten-year follow-up.

Author information

1
Department of Psychiatry, Columbia College of Physicians and Surgeons, USA. jonathaneposner@gmail.com

Abstract

OBJECTIVE:

In 1996 Eilenberg and colleagues reviewed 180 charts and reported that trauma histories were poorly documented at a general psychiatric clinic. This study is a ten-year replication of that work.

METHODS:

A total of 107 randomly selected charts from the same clinic were reviewed for assessment of trauma history. The quality of the assessments was rated.

RESULTS:

Fifty-six percent of charts contained a thorough description of trauma severity, compared with 15% in the initial study. Documentation of posttraumatic symptoms improved significantly in all categories but remained low. Documentation of diagnostic formulations and treatment plans for patients with a trauma history was thorough in a small proportion of charts (14%), as was found in the initial study (9%).

CONCLUSIONS:

Although some improvements were found in recording trauma histories, eliciting such a history did not lead to thorough documentation of posttraumatic symptoms or to inclusion of the history in the diagnostic formulation or treatment plan.

PMID:
18308915
DOI:
10.1176/ps.2008.59.3.318
[Indexed for MEDLINE]

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