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Background The higher mortality rates in people with severe mental illness (SMI) may be partly due to inadequate integration of physical and mental healthcare. Accurate recording of SMI during hospital admissions has the potential to facilitate integrated care including tailoring of treatment to account for comorbidities. We therefore aimed to investigate the sensitivity of SMI recording within general hospitals, changes in diagnostic accuracy over time, and factors associated with accurate recording. Methods and findings We undertook a cohort study of 13,786 adults with SMI diagnosed during 2006–2017, using data from a large secondary mental healthcare database as reference standard, linked to English national records for 45,706 emergency hospital admissions. We examined general hospital record sensitivity across patients’ subsequent hospital records, for each subsequent emergency admission, and at different levels of diagnostic precision. We analyzed time trends during the study period and used logistic regression to examine sociodemographic and clinical factors associated with psychiatric recording accuracy, with multiple imputation for missing data. Sensitivity for recording of SMI as any mental health diagnosis was 76.7% (95% CI 76.0–77.4). Category-level sensitivity (e.g., proportion of individuals with schizophrenia spectrum disorders (F20-29) who received any F20-29 diagnosis in hospital records) was 56.4% (95% CI 55.4–57.4) for schizophrenia spectrum disorder and 49.7% (95% CI 48.1–51.3) for bipolar affective disorder. Sensitivity for SMI recording in emergency admissions increased from 47.8% (95% CI 43.1–52.5) in 2006 to 75.4% (95% CI 68.3–81.4) in 2017 (ptrend < 0.001). Minority ethnicity, being married, and having better mental and physical health were associated with less accurate diagnostic recording. The main limitation of our study is the potential for misclassification of diagnosis in the reference-standard mental healthcare data. Conclusions Our findings suggest that there have been improvements in recording of SMI diagnoses, but concerning under-recording, especially in minority ethnic groups, persists. Training in culturally sensitive diagnosis, expansion of liaison psychiatry input in general hospitals, and improved data sharing between physical and mental health services may be required to reduce inequalities in diagnostic practice., In a cohort study using linked registry data, Hassan Mansour and colleagues examine the factors related to and temporal trends in the accurate recording of severe mental illness diagnoses among individuals admitted to hospitals in England between 2006 and 2017., Author summary Why was this study done? People with severe mental illness (SMI) have increased mortality and morbidity, largely due to preventable medical conditions, and these disparities have the potential to be ameliorated through better healthcare integration. Accurate recognition of SMI during hospital admissions can be critical as it allows continuity of previous pharmacological and supportive treatments and tailoring of inpatient and discharge care to individual needs. What did the researchers do and find? We examined the hospital discharge records of 13,786 individuals with SMI diagnosis from a mental health service, who had 45,706 admissions to English general hospitals between 2006 and 2017. We found that a psychiatric condition is recorded in around two-thirds of general hospital admissions of people with SMI. Recording of SMI diagnosis increased between 2006 and 2017. However, people from ethnic minority and married backgrounds were less likely to have psychiatric diagnosis recorded. Similarly, those with less severe mental or physical health symptoms were also less likely to have diagnosis recorded. What do these findings mean? Despite improvements over the past decade, inequities related to ethnicity remain. Policy-makers and clinicians should endeavor to improve recognition and recording of SMI in general hospital settings to promote integrated physical and mental healthcare. A limitation of our study is that our use of electronic health records for the reference-standard means that some people with SMI may have been misclassified.