The evolving clinical chart. How it reflects and influences psychiatric and medical practice and the quality of care.
The clinical chart constitutes an evolving patient care document. This article compares charts from the turn of the century with those of today. It has changed from a simple user-friendly personal note record to a major medical-legal documentation system. With this evolution have come shifts in clinicians' attitudes toward the chart, a more active role in influencing care for the record, a much more public position of it, and a more homogenized record. It concludes with methods for the practitioners to incorporate the evolving chart into their work so as to further improve their documentation and care.
Soreff
S
S
Westborough State Hospital, Massachusetts.
Gulkin
T
T
Pike
J G
JG
D003219:Confidentiality; D006801:Humans; D008499:Medical Records / Q000592:standards; D011787:Quality of Health Care; D012922:Social Change