Gifford S, Maberry D
Hosp Community Psychiatry. 1979 Aug;30(8):532-5. doi: 10.1176/ps.30.8.532.
A community mental health--mental retardation center developed a computerized problem-oriented record system specifically for use in a full-service community mental health center. It is based on an integrated set of clinical forms that covers all levels of a client's involvement with the center, beginning with his contact as a prospective client and including intake, treatment planning, treatment, and discharge. Most of the forms are computer-generated. Special features of the system include its capability to prompt the clinician about scheduled treatment sessions, follow-ups, and other activities and a scale that rates the client's level of functioning and is keyed to a specially developed master problem list. The authors describe each of the clinical forms used in the system.
一个社区心理健康与智力障碍中心开发了一个专门用于全方位服务社区心理健康中心的计算机化问题导向记录系统。它基于一套综合的临床表格，涵盖了客户与该中心接触的各个层面，从他作为潜在客户的初次接触开始，包括 intake（ intake 可音译为“入院登记”等，具体准确意思需结合上下文，此处直接保留英文以便更准确理解原文语境）、治疗计划、治疗及出院。大多数表格是计算机生成的。该系统的特殊功能包括能够提示临床医生有关预定的治疗疗程、随访及其他活动，以及一个对客户功能水平进行评分并与专门制定的主问题清单相关联的量表。作者描述了该系统中使用的每种临床表格。
