Study objectives: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatric patients. Design: Descriptive, retrospective chart review. Setting: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. Type of participants: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. Interventions: None Measurements and main results: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented ''medically clear'' in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. Conclusion: Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement ''medically clear'' is inaccurate and should be replaced by a thorough discharge note.
