The Problem-Oriented Medical Record as a Training Tool for Staff
Abstract
After numerous deficiencies were found in a psychiatric center's medical records, a task force devised a system that incorporated the four components of the problem-oriented medical record plus other elements required by the center's structure. They divided the record into ten sections and also developed a four-page form for recording the patient's assessment and treatment plan. Two-hour mandatory training sessions were held to teach all levels of mental health staff how to use the new system; various kinds of follow-up instruction were also given. That training, the authors say, was a valuable way to teach staff not only proper record-keeping but also clinical thinking and logical treatment planning.
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