[A documentation form for the consultation-liaison service: development of the CL-BaDo]. 2005

Wolfgang Söllner, and Barbara Stein, and Askan Hendrischke, and Thomas Loew, and Thomas Herzon
Klinik für Psychosomatik und Psychotherapeutische Medizin, Klinikum Nürnberg, Prof. Ernst-Nathan-Strasse 1, D-90419 Nürnberg, Germany. wolfgang.soellner@klinikum-nuernberg.de

OBJECTIVE In consultation liaison (CL) psychiatry and psychosomatics a multicenter documentation form for the assessment of clinical characteristics of patients and CL service delivery is urgently needed for health care planning and future mental health research. METHODS In several steps a joint working party of the psychosomatic and psycho-therapeutic societies in Germany (German College for Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a documentation form for C-L service (CL-BaDo). The goals and quality criteria of the patient registration form are defined in an extended consensus process of C-L experts. A pool of formerly 60 items was reduced to 36 items collecting data concerning sociodemographic characteristics, referral information, anamneses, actual psychiatric and somatic status and diagnoses, C-L interventions and treatment recommendations. To enable comparisons, the formulation of items are adapted to existing inpatient and outpatient documentation forms (Psy-BaDo,EuroQA-CL). A special manual guides the coding of the CL-BaDo. RESULTS 16 CL services in Germany and Austria participated in the testing and pilot study of six months demonstrating the comprehensibility and fast completion of CL-BaDo and consultants' high acceptance of the form. A time-saving and user-friendly electronic version for data entry and data analyses was developed using hand-held technology. CONCLUSIONS The data of the CL-BaDo can be used for 1) quality management and communication purposes with referring departments and 2) for multicenter collaborative studies, mental health care management and care planning.

UI MeSH Term Description Entries
D010865 Pilot Projects Small-scale tests of methods and procedures to be used on a larger scale if the pilot study demonstrates that these methods and procedures can work. Pilot Studies,Pilot Study,Pilot Project,Project, Pilot,Projects, Pilot,Studies, Pilot,Study, Pilot
D011570 Psychiatry The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders.
D011613 Psychotherapy A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. Psychotherapies
D012017 Referral and Consultation The practice of sending a patient to another program or practitioner for services or advice which the referring source is not prepared to provide. Consultation,Gatekeepers, Health Service,Hospital Referral,Second Opinion,Consultation and Referral,Health Service Gatekeepers,Hospital Referrals,Referral,Referral, Hospital,Referrals, Hospital,Consultations,Gatekeeper, Health Service,Health Service Gatekeeper,Opinion, Second,Opinions, Second,Referrals,Second Opinions
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D005858 Germany A country in central Europe, bordering the Baltic Sea and the North Sea, between the Netherlands and Poland, south of Denmark. The capital is Berlin.
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D001523 Mental Disorders Psychiatric illness or diseases manifested by breakdowns in the adaptational process expressed primarily as abnormalities of thought, feeling, and behavior producing either distress or impairment of function. Mental Illness,Psychiatric Diseases,Psychiatric Disorders,Psychiatric Illness,Behavior Disorders,Diagnosis, Psychiatric,Mental Disorders, Severe,Psychiatric Diagnosis,Illness, Mental,Mental Disorder,Mental Disorder, Severe,Mental Illnesses,Psychiatric Disease,Psychiatric Disorder,Psychiatric Illnesses,Severe Mental Disorder,Severe Mental Disorders
D012984 Software Sequential operating programs and data which instruct the functioning of a digital computer. Computer Programs,Computer Software,Open Source Software,Software Engineering,Software Tools,Computer Applications Software,Computer Programs and Programming,Computer Software Applications,Application, Computer Software,Applications Software, Computer,Applications Softwares, Computer,Applications, Computer Software,Computer Applications Softwares,Computer Program,Computer Software Application,Engineering, Software,Open Source Softwares,Program, Computer,Programs, Computer,Software Application, Computer,Software Applications, Computer,Software Tool,Software, Computer,Software, Computer Applications,Software, Open Source,Softwares, Computer Applications,Softwares, Open Source,Source Software, Open,Source Softwares, Open,Tool, Software,Tools, Software
D013001 Somatoform Disorders Disorders having the presence of physical symptoms that suggest a general medical condition but that are not fully explained by another medical condition, by the direct effects of a substance, or by another mental disorder. The MEDICALLY UNEXPLAINED SYMPTOMS must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. In contrast to FACTITIOUS DISORDERS and MALINGERING, the physical symptoms are not under voluntary control. (APA, DSM-V) Briquet Syndrome,Pain Disorder,Somatization Disorder,Medically Unexplained Syndrome,Medically Unexplained Syndromes,Disorder, Somatoform,Somatization Disorders,Somatoform Disorder,Syndrome, Briquet,Syndrome, Medically Unexplained,Unexplained Syndrome, Medically

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