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The problem-oriented medical record as a training tool for staff.

作者信息

Biron R, Goodman P

出版信息

Hosp Community Psychiatry. 1977 Dec;28(12):909-11. doi: 10.1176/ps.28.12.909.

Abstract

After numerous deficiencies were found in a psychiatric center's medical records, a task force devised a system that incorporated the four components of the problem-oriented medical record plus other elements required by the center's structure. They divided the record into ten sections and also developed a four-page form for recording the patient's assessment and treatment plan. Two-hour mandatory training sessions were held to teach all levels of mental health staff how to use the new system; various kinds of follow-up instruction were also given. That training, the authors say, was a valuable way to teach staff not only proper record-keeping but also clinical thinking and logical treatment planning.

摘要

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