Head L, Campbell-Hewson G L, O'Keane V
Addenbrooke's Hospital, Cambridge.
J R Coll Physicians Lond. 1999 Jan-Feb;33(1):51-5.
To determine whether psychosocial assessments of patients presenting to the Accident and Emergency (A&E) Department at Addenbrooke's Hospital, Cambridge, with deliberate self-harm are recorded adequately in the case notes, using the criteria of the 1994 Royal College of Psychiatrists' consensus statement on managing adult deliberate self-harm in hospital.
A cross-sectional study of case notes.
A total of 338 patients (accounting for 404 episodes of deliberate self-harm) who presented consecutively between 1 January and 30 June 1996.
56% of episodes resulted in admission to a general hospital bed. In only 11% of conscious patients were adequate psychological assessments recorded in the case notes. Little psychosocial information was recorded in the notes of those patients discharged without follow-up from accident and emergency.
In the A&E department of this teaching hospital, there is inadequate recording of important psychological information in the case notes of patients who present with deliberate self-harm.
根据1994年皇家精神科医学院关于医院成人蓄意自我伤害管理的共识声明标准，确定剑桥阿登布鲁克医院急诊科因蓄意自我伤害就诊患者的心理社会评估在病历中是否有充分记录。
病历横断面研究。
1996年1月1日至6月30日期间连续就诊的338例患者（共404次蓄意自我伤害事件）。
56%的事件导致患者入住综合医院病床。病历中仅记录了11%有意识患者的充分心理评估。在急诊科未经随访就出院的患者病历中，记录的心理社会信息很少。
在这家教学医院的急诊科，因蓄意自我伤害就诊患者的病历中重要心理信息记录不足。
