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以问题为导向的医疗记录作为员工的培训工具。

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

在一家精神病中心的病历中发现诸多缺陷后,一个特别工作组设计了一个系统,该系统纳入了问题导向型病历的四个组成部分以及该中心结构所要求的其他要素。他们将病历分为十个部分,还制定了一份四页的表格用于记录患者的评估和治疗计划。举办了两小时的强制培训课程,向各级心理健康工作人员传授如何使用新系统;还提供了各种后续指导。作者表示,那次培训是一种宝贵的方式,不仅能教会工作人员正确的病历记录方法,还能培养他们的临床思维和合理的治疗规划能力。

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