Use of electronic health records in identifying drug and alcohol misuse among psychiatric in-patients

Aims and method To assess the usefulness of the electronic patient record, we used the search engine Clinical Record Interactive Search (CRIS) to scan all acute admissions during 2008 for possible substance use disorders. In addition, screening interviews were undertaken with 75 in-patients, and documentation in their files was compared with results of screening interviews. Results Of 839 acute admissions during 2008, 47% of males and 29% of females had reference to a substance misuse problem in their file. Documentation was unsystematic and inconsistent and mostly occurred in progress notes rather than in structured questionnaires. Screening interviews and manual review of files of 75 current in-patients confirmed that substance use disorders were common, but poorly documented. Clinical implications The study highlights the power of search engines in scanning electronic clinical records, but also identified the limitations of unsystematic documentation in research and practice. Mental health staff were reluctant to diagnose or rate severity of substance misuse problems.