Variability in documentation of neurological and psychiatric examinations among emergency department patients with behavioral health-related presentations: a retrospective study.

Background: Emergency departments (EDs) serve as a critical safety net for individuals experiencing acute behavioral health crises, a population that faces substantial medical morbidity and well-documented disparities in healthcare delivery. Thorough physical and neuropsychiatric assessment is essential in this setting to identify medical conditions that may mimic or exacerbate psychiatric symptoms. Incomplete documentation of these assessments may reflect gaps in care processes and represent a potential marker of inequity. Objective: To characterize the completeness of documented neurological and psychiatric examinations among adult ED patients presenting with primary behavioral health-related chief complaints and to assess whether documentation patterns suggest persistent gaps in standardized evaluation. Methods: We conducted a retrospective electronic medical record review of adult patients presenting to a large, urban academic ED between May 2020 and May 2021 with behavioral health-related chief complaints requiring medical clearance prior to psychiatric evaluation. Documentation of neurological and psychiatric examination components was systematically abstracted using predefined operational definitions. Results: Of 1,613 screened encounters, 507 met inclusion criteria (mean age 39.1 ± 14 years; 66.7% male; 49.7% African American). Suicidal ideation was the most common presenting complaint (49.9%), and 55.0% of patients presented voluntarily. A general neurological or mental status examination was documented in 94.5% of encounters; however, specific neurological components such as Glasgow Coma Scale (9.3%) and deep tendon reflexes (1.4%) were infrequently recorded. Psychiatric examinations were documented in 63.3% of cases, with behavioral observations most commonly reported and cognition and memory least frequently assessed. Conclusions: Documentation of neurological and psychiatric examinations for ED patients with primary behavioral health presentations remains inconsistent, particularly for specific examination components. When documentation is used as a surrogate for care processes, these findings suggest variability in the thoroughness of evaluation for a vulnerable population. Establishing standardized, evidence-based expectations for neuropsychiatric assessment and documentation in the ED may represent an important step toward improving patient safety and promoting equity in emergency psychiatric care.