Epic Fail! Poor Neuropsychiatric Documentation Practices in Emergency Psychiatric Patients

Background: There is a strong association between mental illness and poor physical health. However, research indicates that the standard of physical examinations performed on patients with psychiatric illnesses is sub-optimal, falling short of recommended/expected assessments. Objective: This study aimed to assess the completeness of the neurological and psychiatric examinations performed by emergency physicians in a level 1 trauma centre with a dedicated psychiatric emergency centre. Methods: A retrospective chart review of 50 consecutive emergency psychiatric patients was performed. Each of the 50 patients had been “medically cleared” and deemed stable for transfer to inpatient psychiatry. Results: The documented neurologic and psychiatric examinations were generally poor. Mood and affect were documented in less than 50% of cases. Suicidality was documented in less than 1/3 of the patients who presented with a chief complaint of suicidal ideation. Only one patient had a documented a mini-mental status examination. 16% of patients did not have their orientation status documented. More than half did not have a cranial nerve examination. Less than 25% had their gait or reflexes tested. 28% of patients had their strength tested and 12% had a sensory examination performed. Conclusions: Most psychiatric patients are not receiving a thorough neuropsychiatric physical examination by emergency providers, an alarming finding deserving more scrutiny. Additional research is needed to ascertain which components of the neurological and psychiatric examination are the highest yield and would have the greatest impact patient care outcomes and disposition. Interdisciplinary consensus must also be reached on what constitutes an adequate examination for patients with varying severity of neuropsychiatric presentations (e.g., suicidal ideation, altered mental status, frank psychosis).