Bradshaw Kelsey M, Donohue Brad, Wilks Chelsey
University of Nevada, Las Vegas, Las Vegas, NV, U.S.A.
University of Washington, Seattle, WA, U.S.A.
Aggress Violent Behav. 2014 May;19(3):242-250. doi: 10.1016/j.avb.2014.04.010.
Errors have been found to frequently occur in the management of case records within mental health service systems. In cases involving interpersonal violence, such errors have been found to negatively impact service implementation and lead to significant trauma and fatalities. In an effort to ensure adherence to specified standards of care, quality assurance programs (QA) have been developed to monitor and enhance service implementation. These programs have generally been successful in facilitating record management. However, these systems are rarely disseminated, and not well integrated. Therefore, within the context of interpersonal violence, we provide an extensive review of evidence supported record keeping practices, and methods to assist in assuring these practices are implemented with adherence.
人们发现，心理健康服务系统中的病例记录管理经常出现错误。在涉及人际暴力的案例中，这些错误已被发现会对服务实施产生负面影响，并导致重大创伤和死亡。为确保遵守特定的护理标准，已制定质量保证计划（QA）来监督和加强服务实施。这些计划在促进记录管理方面总体上是成功的。然而，这些系统很少得到推广，也没有很好地整合。因此，在人际暴力的背景下，我们对有证据支持的记录保存做法以及有助于确保这些做法得到切实执行的方法进行了广泛的综述。
