Am J Psychiatry 1977; 134:38-41
Copyright © 1977 by American Psychiatric Association
A computer-assisted, goal-oriented psychiatric progress note system
MJ Meldman, D Harris, RJ Pellicore and EL Johnson
The authors describe a computer system that develops a structured progress
note for inclusion in the medical record. The progress note system reflects
a goal-oriented patient treatment process and also provides for
retrospective analysis of progress note information to accommodate research
and review objectives. The system, which has met with a high degree of
clinician acceptance, has resulted in improved case documentation, more
timely and comprehensive notes, a higher level of objectivity, and a
considerable reduction in the time required to organize and record progress
note data.
