Quality and use of trauma histories obtained from psychiatric outpatients: a ten-year follow-up

Psychiatr Serv. 2008 Mar;59(3):318-21. doi: 10.1176/ps.2008.59.3.318.


Objective: In 1996 Eilenberg and colleagues reviewed 180 charts and reported that trauma histories were poorly documented at a general psychiatric clinic. This study is a ten-year replication of that work.

Methods: A total of 107 randomly selected charts from the same clinic were reviewed for assessment of trauma history. The quality of the assessments was rated.

Results: Fifty-six percent of charts contained a thorough description of trauma severity, compared with 15% in the initial study. Documentation of posttraumatic symptoms improved significantly in all categories but remained low. Documentation of diagnostic formulations and treatment plans for patients with a trauma history was thorough in a small proportion of charts (14%), as was found in the initial study (9%).

Conclusions: Although some improvements were found in recording trauma histories, eliciting such a history did not lead to thorough documentation of posttraumatic symptoms or to inclusion of the history in the diagnostic formulation or treatment plan.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Ambulatory Care / statistics & numerical data*
  • Diagnostic and Statistical Manual of Mental Disorders
  • Documentation / standards*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Medical History Taking / standards*
  • Mental Disorders / diagnosis*
  • Mental Disorders / epidemiology
  • Mental Disorders / therapy*
  • Middle Aged
  • Stress Disorders, Post-Traumatic / epidemiology*
  • Stress Disorders, Post-Traumatic / psychology*
  • Surveys and Questionnaires