A safety net with holes
The emergency department is where people go when they have nowhere else to turn.
For someone in a mental health crisis, that visit is a pivotal moment. A thorough exam can catch serious medical problems pretending to be psychiatric ones.
But a new study of 507 ER visits suggests parts of that exam are often left out, at least in the written record.
Behavioral health visits to emergency departments have climbed for years. Suicidal thoughts, psychosis, and severe anxiety all bring people through the door.
Before a psychiatric team takes over, an ER doctor usually does something called medical clearance. That means checking for physical problems that could cause or worsen symptoms.
A brain infection, low blood sugar, a head injury, or a drug reaction can all look like psychiatric illness. Miss them, and care goes the wrong direction.
Old way versus what is changing
For decades, medical clearance varied wildly from hospital to hospital. Some did full workups. Others waved patients through.
Today, many groups push for standardized exams. The idea is simple: every patient deserves the same careful check, regardless of how they present.
But here is the twist: even at an academic hospital, documentation shows big gaps.
How the study worked
Researchers reviewed electronic medical records from a large urban academic emergency department.
They looked at adults who arrived between May 2020 and May 2021 with behavioral health complaints, meaning things like suicidal thoughts, agitation, or psychosis.
Of 1,613 screened charts, 507 met the study's criteria. Mean age was 39. Two-thirds were men. Nearly half were African American.
On the surface, things looked okay. A general neurological or mental status exam was documented in 94.5% of visits.
Dig deeper, and the gaps appear.
Glasgow Coma Scale, a basic score of consciousness, was recorded in only 9.3% of charts. Deep tendon reflexes, a quick check of the nervous system, appeared in just 1.4%.
Psychiatric exam documentation showed up in 63.3% of charts. Behavior was usually described. Memory and thinking were often skipped.
Why the missing pieces matter
Documentation is not the same as what happened at the bedside. A doctor may have done a full exam but written a short note.
Still, the chart is the main record of care. If something is missing, nurses, psychiatrists, and later clinicians cannot see it.
For patients in a crisis, that gap can shape their entire hospital journey.
A question of equity
Behavioral health patients already face discrimination in medicine. Their physical complaints are often blamed on their psychiatric diagnosis. It even has a name: diagnostic overshadowing.
A thorough, documented exam is a protection against that bias. It says every symptom got checked, not assumed away.
When that documentation is spotty, it signals inconsistent care for a population that already carries more than its share of medical problems.
The authors frame this as both a safety issue and an equity issue. Behavioral health patients come with real medical morbidity.
A brain bleed can mimic agitation. A thyroid storm can mimic mania. Without a careful exam, those get missed.
Setting clear, standardized expectations for what gets checked and documented is a concrete step toward fairer care.
If you or a loved one heads to an ER during a mental health crisis, you have the right to a full medical evaluation.
You can advocate. Ask: Was a full neurological exam done? Were vital signs and consciousness checked? Was blood work run to rule out medical causes?
Bringing a friend or family member helps. They can ask questions when the patient cannot. Writing down concerns ahead of time also helps.
If you feel the exam was rushed, it is reasonable to ask for more. Most doctors will respond to a calm, specific request.
This was a single-site, retrospective chart review at one academic urban ER. Practices differ widely across hospitals, so these numbers may not match other settings.
The study measured documentation, not the actual exam at the bedside. Some care may have happened without making it into the record.
The time period covered the early COVID-19 pandemic, which stressed emergency departments in unusual ways.
The authors call for standardized, evidence-based expectations for neuropsychiatric exams in the ED.
Some hospitals are already building checklists and electronic record prompts that nudge doctors to complete and document each step. Early evidence suggests these tools work.
Patient advocacy groups are also pushing for clearer rights and expectations during mental health visits. Real change will take policy, training, and culture shifts together.
For now, awareness is a start. Knowing what a thorough ER exam should include gives patients and families tools to ask for better care.
