NCJ Number
44732
Date Published
1977
Length
42 pages
Annotation
RECORDKEEPING-RELATED PROCEDURES ARE OUTLINED IN A MANUAL FOR USERS OF THE CLIENT-ORIENTED RECORD DEVELOPED AT THE GOOD SHEPHERD CENTER FOR TROUBLED ADOLESCENT GIRLS IN BALTIMORE, MD.
Abstract
THE PERSON-ORIENTED RECORD (POR) PROVIDES A SYSTEMATIC MEANS OF FOCUSING TREATMENT AND MAINTAINING QUALITY CARE. THE CORE OF THE POR IS A LISTING OF CLUSTERS OF PROBLEMS AND STRENGTHS IN SEVEN CATEGORIES. EACH CATEGORY INCLUDES GOAL AND TREATMENT PLAN DEVELOPED BY THE TREATMENT TEAM. ALL OTHER NOTATIONS IN THE POR ARE KEYED TO THE LISTING. THE POR REQUIRES THE TREATMENT TEAM TO FOCUS ON EACH CLIENT'S PROBLEMS, STRENGTHS, GOALS, PLANS, AND IDENTIFIABLE PROGRESS. THE RECORD ALLOWS ANYONE TO FOLLOW ANY CLIENT PROBLEM FROM ADMISSION TO DISCHARGE AND TO ASSESS WHAT HAS BEEN ACCOMPLISHED IN THE TREATMENT PROCESS. THE PROCEDURAL MANUAL DESCRIBES IN DETAIL THE RECORDKEEPING TASKS OF THE TREATMENT TEAM AS THEY RELATE TO THE FOLLOWING COMPONENTS OF THE POR: DATA BASE; PREEVALUATION CONFERENCE; EVALUATION CONFERENCE; PROGRESS NOTES; PROGRESS REVIEWS; CASE ACTIVITY FORM; UNUSUAL INCIDENT REPORT; AND STATISTICAL INFORMATION CARD. THE CONTENT OF THE COMPLETED CASE RECORD IS DESCRIBED, AND KEY TERMS ARE DEFINED. A CASE EXAMPLE, INCLUDING COMPLETED VERSIONS OF EACH POR COMPONENT, IS INCLUDED. FOR THE REPORT DOCUMENTING POR DEVELOPMENT, IMPLEMENTATION, AND EVALUATION, SEE NCJ-44731.