An Integrated System for Computerized Patient Records

Abstract

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.