A NEGLECTED DOCUMENT—THE MEDICAL RECORD OF THE STATE PSYCHIATRIC HOSPITAL PATIENT
BRUNO RADAUSKAS M.D.1,
ALBERT A. KURLAND M.D.2, , and
SIDNEY GOLDIN B.S.
1 Superintendent, Spring Grove State Hospital, Baltimore 28, Md.
2 Director of Research, Maryland State Department of Mental Hygiene.
Approximately 17,000 patient medical records were analyzed at the Spring Grove State Hospital over a 4-year period in order to determine what might be done to increase the usefulness of this document. The experiences and results reported by this study emphasized again and again that there are no substitutes for an adequately subsidized, staffed and maintained medical records department. Compromise in this area only compounds confusion, for slowly and insidiously the record is constantly changing in order to meet the development of new methods of treatment and care. This change uncontrolled will result in an increasingly costly and ineffective document. As more sophisticated instrumentation appears in the area of data processing and retrieval, the sound structure of a good medical document will become an increasingly important necessity.
