title: An information system for clinical recording, administrative decision making, evaluation, and research.
abstract: An information system suitable for clinical, administrative, and research uses is described. The source document is a modified problem-oriented record in which progress on each problem can be measured by a goal attainment scaling technique during therapy, at termination, and at follow-up. The model deals with the problem of how specific the goals should be by establishing two evaluation procedures. One procedure is based on predefined long-term general goals of therapy. The other procedure deals with therapist defined short-term goals and procedures.
mesh_terms: D003657:Decision Making; D005069:Evaluation Studies as Topic; D006040:Goals; D006801:Humans; D007256:Information Systems; D008499:Medical Records; D008501:Medical Records, Problem-Oriented; D001523:Mental Disorders / Q000628:therapy; D008605:Mental Health Services; D009934:Organization and Administration; D010347:Patient Care Planning; D012106:Research