There is inadequate recording of physical health parameters, including cardiovascular risk factors, in the case notes of psychiatric patients in rehabilitation and recovery.
Inadequate cardiovascular risk documentation in psychiatric notes may compromise care; leaves open whether standardized recording improves monitoring or outcomes.
Aims and Method The aim of this survey was to determine details recorded about the physical health of patients in rehabilitation and recovery. All medical and nursing notes from January 1998 to March 2003 were reviewed. Case notes from 63 patients were studied. Results There was mention in less than 13 of the patients' notes (18%) of smoking, diet, exercise or prolactin levels; weight, blood pressure, electrocardiogram, erythrocyte sedimentation rate or lipids were mentioned in less than 20 (30%). A blood sugar test was performed in only 16 patients (25%) in the past year and 38 patients (59%) had a record of a test in the past 5 years. These results suggest that there is inadequate recording of the physical health parameters in patients in rehabilitation and recovery. Clinical Implications The physical healthcare of patients with schizophrenia is prioritised in the National Institute for Clinical Excellence (NICE) clinical guidelines, which specifically mention the monitoring of endocrine disorders such as diabetes and hyperprolactinaemia, cardiovascular risk factors, such as blood pressure and lipids, and lifestyle factors such as smoking. Routine recording of physical health indices should be mandatory and staff may need further training to enable them to do this.
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Jayne Greening (2005) studied this question.
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