A documentation form for the consultation-liaison service: development of the CL-BaDo

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.