A computer-assisted, goal-oriented psychiatric progress note system.
The authors describe a computer system that develops a structured progress note for inclusion in the medical record. The progress note system reflects a goal-oriented patient treatment process and also provides for retrospective analysis of progress note information to accommodate research and review objectives. The system, which has met with a high degree of clinician acceptance, has resulted in improved case documentation, more timely and comprehensive notes, a higher level of objectivity, and a considerable reduction in the time required to organize and record progress note data.
D003201:Computers; D006801:Humans; D008499:Medical Records; D008501:Medical Records, Problem-Oriented; D008962:Models, Theoretical; D011570:Psychiatry