Documentation of Psychosis Risk Screening in Same‐Day Adolescent Behavioural Health Consultations

BACKGROUND: Early detection of psychosis is associated with improved outcomes for patients with serious mental illness. METHODS: Psychosis screening items were added to an electronic medical record template used for same-day consultations by behavioural health clinicians in an adolescent/young adult medical clinic. We conducted a retrospective chart review to characterise psychosis prevalence and documentation of psychosis screening. RESULTS: Documentation of any responses to psychosis screening items was present in 28% of consultations (n = 116). Among consultations where providers directly inquired about psychosis (14%; n = 59), 20% (n = 12) documented ≥ 1 psychosis risk item, representing 10 unique patients. For three of these patients, this was an initial identification of psychosis concern. CONCLUSIONS: Despite inclusion of psychosis screening items on a consultation template, most behavioural health consultations did not include documentation of psychosis risk assessment. Documented direct clinician inquiry into psychosis risk was associated with the discovery of previously unidentified psychosis risk factors and symptoms.