A useful medical record system for a decentralized mental hospital.

Abstract

T HE MEASURE of a good medical record system is whether it permits the maximum use of records to meet the hospital’s objectives. As the goals and services of mental hospitals become increasingly varied and complex, the uses of records change and increase correspondingly, and the record system must be readily adaptable. A system that sufficed for the custodial mental hospital is far from adequate for the broader programs that are developing in hospitals today. And as the hospitals join forces with community mental health centers in more comprehensive programs, their record systems will have to undergo even greater changes. The current trend toward decentralized units in mental hospitals has implications for medical record systems. When a hospital changes its administrative organization, staffing patterns, and treatment programs, it should adapt its medical record system to fit the needs created by these changes. Although patterns of decentralization vary from one hospital to another, it is axiomatic that patients’ records should be kept where they are readily accessible to the treatment personnel who must use and contribute to the files. In a hospital divided into treatment units in which patients remain for the duration of their hospital stay, with each unit assigned a more or less permanent staff, each patient’s record might well be kept on his unit for as long as he is on the hospita! books. If follow-up care for patients on convalescent leave and for discharged patients is given in a central outpatient unit, only records of current inpatients would remain on the treatment units. If a separate medical-surgical unit is maintained, a patient’s record should accompany him to and from there. In such a system a central medical record office would maintain records of all patients who were deceased or discharged and provide services that are essential to the hospital as a whole and not peculiar to any one treatment unit. A primary function of the central office would be to coordinate the unit’s medical record activities, for they should not function autonomously, but rather as components of a well-coordinated system. This pattern of organization can be more speficially described in terms of the medical record functions that are assigned to the psychiatric treatment units and those that remain centralized, and the relation of these functions to each other.