Digital documentation in forensic psychiatric hospitals

Clinical documentation is a central component of care for inmates in forensic institutions. Their completeness and traceability determine the quality of treatment, risk assessment and decisions about granting leave. Due to federal legal regulations, separate state advances are required for studies on clinical documentation in German forensic institutions. A first contribution to this was made with this investigation of digital documentation in Bavarian forensic institutions. At 12 forensic psychiatric hospitals, 120 randomly selected files created in electronic hospital information systems and a survey of 133 treating staff were used to examine which systems had been used in recent years, how structured legally described documentation could be recorded and how documentation quality was assessed by staff. Overall, many digital input masks allowed a structured general information collection via specific fields or selection options, although the level of structure varied significantly. The information provided by staff reflected the type and structural level of the recording systems used. There is a need for improvement in the documentation of risk and therapy-relevant information. The quality of care could be improved by establishing a hospital information system that conserves resources through uniform, highly structured input masks and ensures comparability of digital documentation.