THE PROBLEM-ORIENTED RECORD IN PSYCHIATRY

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Abstract
While the problem-oriented approach to record-keeping is gaining wide usage and enthusiastic acceptance in the general medical community, it has made to this time little impact in psychiatry. This paper describes how the basic components of the problem-oriented system can be effectively adapted for use in psychiatric practice. This uniquely “psychiatric” adaptation of the problem-oriented record was employed successfully on a 28-patient adult unit and consists of eight clearly denned elements. The system was found to meet or exceed the major criteria for excellence in medical record-keeping. In addition it was found to have the following advantages: It is adaptable for use in any type of psychiatric treatment setting. It allows for more precise determination of treatment goals and patient response; it offers more precise guidance to staff workers, while at the same time increasing both their learning and their sense of participation in the therapeutic task; it is readily adaptable for research use; and it provides the psychiatrist with a practical and workable instrument than can enhance both his patient's care and his own continued professional growth.

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