Psychiatry: case notes indicate impending seclusion

When psychiatric patients pose a danger to themselves or others, the use of coercion is sometimes unavoidable. Measures such as relocation to an isolation room or forced medication are regarded as a last resort, however: they are kept to a minimum and their use is strictly regulated.

Identifying warning signs early on

Various methods are already in use to detect the risk of violence early on and provide the possibility of de-escalation. These methods often focus on patient characteristics and patient-staff interaction, but are not regarded as very reliable.

Researchers from the University of Basel and the Psychiatric University Clinics (UPK Basel) chose a new approach in the current study. They looked for indications of an emerging escalation in the case notes. Medical, psychological and nursing staff use these to document the treatment and prior course of the illness.

Longer and more emotional notes

The retrospective examination encompassed the records of 26 adult patients who ultimately required seclusion. A patient group of equal size with identical diagnoses, for whom coercive measures were not required, was used as a comparison. The basis for the qualitative and quantitative text analysis was the notes from the three days preceding an escalation.

The results showed that the case notes before seclusion were more extensive, meaning they contained a significantly higher number of words. “It seems that the attending staff describe problematic behavior more comprehensively in order to improve information transfer between different shifts, justify upcoming coercive measures and ensure that they are legally protected,” says Dr. Clara Stepanow, author of the study.

The qualitative content analysis showed that the healthcare staff used subjective emotional expressions more frequently in the days before seclusion, thereby expressing their concerns, worries and difficulties in the otherwise factual notes.

Automated text analysis possible

Before a coercive measure, the behavior of patients was also often described using negative terms such as “agitated”, “irritable” and “loud”; the expression “threatening” was only used for patients who were later secluded. Expressions such as “manageable” also indicated a difficult situation, albeit one that staff were able to defuse. Finally, notes recording sleep loss, refusal of medication, high contact frequency and demanding behavior proved to be precursors to seclusion.

“Our study demonstrates previously little-used factors that could be helpful in improving risk evaluation,” says study leader and psychiatrist Dr. Christian Huber. “If the subjective perception of healthcare professionals can be integrated properly into electronic documentation practice, automated text analysis could help in future to prevent coercive measures through timely intervention.”

contact for scientific information:
Dr. Clara Stepanow, University of Basel / Psychiatric University Clinics Basel, Tel. +41 61 325 81 71, email:
Prof. Dr. Christian Huber, University of Basel / Psychiatric University Clinics Basel, Tel. +41 61 325 81 71, email:

original publication:
Clara Stepanow, Jefim Stepanow, Marc Walter, Stefan Borgwardt, Undine E. Lang, Christian G. Huber
Narrative Case Notes Have the Potential to Predict Seclusion Three Days in Advance: A Mixed-Method Analysis
Frontiers in Psychiatry (2019), doi: 10.3389/fpsyt.2019.00096

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