An integrated system for computerized patient records.
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.
D003155:Community Mental Health Centers / Q000458:organization & administration*; D003201:Computers; D005568:Forms and Records Control / Q000379:methods; D008499:Medical Records; D008501:Medical Records, Problem-Oriented; D010347:Patient Care Planning / Q000458:organization & administration*; D013781:Texas