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KCI등재 학술저널

정신과 의무기록 작성지침 개발 및 적용 후 입원의무기록의 질적 변화 비교 연구

Development of Guideline for Psychiatric Medical Record and Quality Improvement Following Its Application

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Objectives Medical records are used to store and communicate information about patient treatment. Nowadays, the problem oriented medical record (POMR) is the most frequently used method for medical records. The POMR has the advantage of evaluating the course of treatment;however, it is also criticized for focusing on just symptoms and signs. We propose new guidelines for psychiatric medical records based on a modified POMR. Methods We organized a research team of psychiatrists and psychiatric residents and, held weekly research meetings from March 2005 until May 2006. Under close psychiatric chart review, we found several problems with the POMR system, and based on these findings, we discussed various ways of modifying it. Results We propose the following AMC psychiatric medical record guidelines:1) Problem lists should be classified into seven categories:psychiatric symptoms, function, risk, environment, special treatment, drug side effects, and medical problems. Additionally, treatment course should be described accordingly. 2) Spontaneous reports by patients should be classified as subjective information, and any contents explored by the clinician, as objective information. Brief scales should be included for the quantitative description of symptoms. 3) Assessment should include symptom severity, treatment response, compliance, and suicidal or violent risk at evaluation point. 4) Specific management strategies such as rationale for dosage adjustment, detailed psychotherapeutic intervention, and psychoeducation should be described in the plan. Conclusion This is one of a few studies proposing guidelines for psychiatric medical records. The application of these will improve the quality of medical records and it is hoped that such guidelines will be used broadly.

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