Department of Psychiatry, University of North Carolina, Campus Box 7160, Chapel Hill, NC, 27599-7160, USA.
Acad Psychiatry. 1990 Sep;14(3):157-63. doi: 10.1007/BF03341289.
The quality of mental status examination (MSE) reports in consecutive admission notes by psychiatric residents was compared before and after the introduction of a structured, pre-printed MSE form that had been designed for teaching and quality of care purposes. We found the use of the form to be associated with a marked improvement in the quality of the reports; however, an important item not on the form was less likely to be recorded than with an unstructured record of the MSE. We conclude that the use of structured MSE forms leads to a significant improvement in the comprehensiveness of MSE records. We therefore recommend that some version of a comprehensive, structured MSE form be adopted for use on adult inpatient psychiatry units where residents are being trained.
比较了精神病住院医师连续入院记录中的精神状态检查（MSE）报告在引入专为教学和护理质量目的而设计的结构化、预印 MSE 表格前后的质量。我们发现使用该表格与报告质量的显著改善有关；然而，表格上没有的一个重要项目比 MSE 的非结构化记录更不可能被记录。我们得出结论，使用结构化 MSE 表格可显著提高 MSE 记录的全面性。因此，我们建议在培训住院医师的成人精神病住院病房使用某种版本的全面、结构化的 MSE 表格。
