Andersen T, Johansson B M, Lindberg M, Stenwall R
Psykiatriska kliniken, Norrlands Universitetssjukhus, Umeå.
Lakartidningen. 1999 Apr 28;96(17):2102-6.
During recent decades psychiatric health care has become increasingly complex due to substantial clinical improvements and to the growing need of integrating psychiatric services with other health and welfare services in the community. The traditional psychiatric record format is incompatible both with these requirements and with the practical advantages and difficulties of modern computer technology. In a collaborative effort involving most professional categories at three psychiatric units in the county of Västerbotten in northern Sweden, a new structured format for medical records was developed. The basic feature is a structured summary of background factors, social situation, drug habits, and general health, which is reviewed and updated as necessary. The psychiatric condition is described in some detail, including onset and course, symptomatology, personality factors, diagnosis, treatment results, suicidality, etc. Day to day treatment is outlined in in- and out-patient treatment plans, which are evaluated and revised at regular intervals. The new record format, which is used by all categories of health care professionals, is intended to promote goal-directed treatment and professional collaboration, and is easily adapted to computer technology.
近几十年来，由于临床水平的大幅提高以及社区精神科服务与其他健康和福利服务整合需求的不断增长，精神卫生保健变得日益复杂。传统的精神科病历格式既不符合这些要求，也不适应现代计算机技术的实际优势和困难。在瑞典北部韦斯特博滕县三个精神科单位的大多数专业类别的共同努力下，开发了一种新的结构化病历格式。其基本特征是对背景因素、社会状况、药物使用习惯和总体健康状况进行结构化总结，并根据需要进行审查和更新。对精神状况进行了较为详细的描述，包括发病情况和病程、症状学、人格因素、诊断、治疗结果、自杀倾向等。门诊和住院治疗计划概述了日常治疗情况，并定期进行评估和修订。这种新的病历格式供各类医疗保健专业人员使用，旨在促进目标导向治疗和专业协作，并且很容易适应计算机技术。
