How Often, where and by whom are Adverse Experiences Recorded in Clinical Records of Service-Users Under the Care of an Early Intervention in Psychosis (EIP) Service?

TL;DR

This study examines how often adverse experiences are recorded in clinical records of people receiving early psychosis care in the UK.

Contribution

The study provides new insights into documentation practices of adverse experiences in early intervention in psychosis services.

Findings

64.6% of clinical records documented at least one adverse experience.

Psychiatrists were the most frequent recorders of adverse experiences.

Recorded rates were lower than expected based on prior research.

Abstract

Research indicates high prevalence rates of adverse experiences in people experiencing first-episode psychosis. Despite recommendations that mental health staff should routinely ask about adverse experiences, documentation indicates these are not being recorded in service-users’ clinical records across different mental health settings. This study audited 48 service-user records in a UK early intervention in psychosis (EIP) community mental health service to examine how often, where, and by whom adverse experiences were recorded. Searching for 22 adverse experience terms, 64.6% of clinical records documented at least one adverse experience, with 80.6% reporting more than one. The profession that most often recorded adverse experiences in service-users’ clinical records was psychiatrists. While EIP services may document adverse experiences more frequently than other community mental health settings, recorded rates remain lower than expected based on previous research prevalence rates. Further studies should consider adverse experiences recording across UK EIP services to ensure service-users with adverse experiences receive appropriate support.

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