BRIEF
COMMUNICATIONS
9. Bass UF,
Brown
BS: Methadone
maintenance
detoxification: a comparison of retention teristics. Int J Addict 8:889-895, 1973
The
Use
Mental
and client
charac-
10. Aron WS, Daily D: Short- and long-term therapeutic nities: a follow-up and cost effectiveness comparison.
Medical
Records
in Community
Centers
M. VICKAR,
M.D.,
AND MARIJAN
HERJANIC,
M.D.
in other The authors’ questionnaire survey of147 community mental health centers revealed that 36 (24%) were using problem-oriented medical records (POMR), 34 (23%) planned to use them, 23 (16%) were uncertain, and54 (37%) had not considered using them. According to the responses ofcenters that were using POMR and the authors’ experience, the advantages of POMR in psychiatry are similar to their advantages in other specialties, and the difficulties in implementing this system are related to the definition of “problems.”
WEED’S
commumt J Ad-
dict9:619-636, 1974
of Problem-Oriented Health
BY GARRY
and methadone
rates
of problem-oriented
INTRODUCTION
medical
psychiatric
facilities
and
undertook
a survey
of other mental health centers. Using the September 1973 Directory ofFederally Funded Community Mental Health
Centers
(12),
we
sent
questionnaires
to all
community mental health centers in operation at the end of August 1974. We inquired about the adoption, acceptance, and advantages of POMR.1
FINDINGS
Three hundred out in August swered. Eleven
thirty-four questionnaires 1974; 158 (47%) were replies had to be dropped
lations
they
because
were
were sent returned anfrom calcu-
incomplete.
about the use of POMR in psychiatric practice than in other medical specialties. Considering the many advantages claimed for POMR in psychiatry (7), we were sunprised to find only an occasional report of their use in
Thirty-six of the 147 centers (24%) were using POMR. These centers were apparently distributed randomly throughout the United States. Of these 36 centens, 19 used POMR for both inpatients and outpatients, 8 for inpatients only, and 9 for outpatients only. The average duration ofuse was about 12 months (1 center claimed to have been using a modified form of POMR for 27 years). Thirty-four of the 147 centers (23%) planned to irnplement POMR, and 23 of the centers (16%) were Uncertain. The remaining 54 centers (37%) had not con-
this
sidered
records
ond
(POMR)
keeping
(1)
in many
has
led
medical
to a reevaluation
centers.
Following
adoption of this system, publications appeared ing POMR and encouraging their acceptance cialties of medicine (2-4). More recently
been
some
uation
of
field
questioning this
new
and approach
(8, 9). It may
be that
attempts (5,
of nec-
at critical 6).
Less
psychiatrists
the
endorsin all spethere has is
have
evalknown
bene-
fited from the experience of colleagues in other branches of medicine (10, 11) and approached the subject with caution. The POMR was first used in the inpatient service of Malcolm Bliss Mental Health Center, St. Louis, Mo., on July 1 , 1974. We wondered about the extent ofits use
so made collection
improved Dr. Vickar is Instructor Professor of Psychiatry, cine, 1420 Grattan St., Assistant Superintendent, Louis, Mo.
340
Am
in Psychiatry and Dr. Henjanic is Associate Washington University School of McdiSt. Louis, Mo. 63104. Dr. Henjanic is also Malcolm Bliss Mental Health Center, St.
J Psychiatry
133:3,
March
1976
using
POMR.
Twenty-four of the 36 centers using POMR (67%) agreed that their use improved their record keeping in terms of organization, readability, and identification of problem areas. The better organization al-
using ‘Copies quest.
for easier supervision for research purposes.
patient POMR of the
had
care, mixed
questionnaire
the
of residents and data When asked about
36 respondents
reactions, are available
but from
who 23 (64%) Dr.
Vickar
were beon re-
BRIEF
lieved that patients benefited from the more consistent approach in documentation. Thirteen (36%) were not aware ofa change in length ofstay, but one respondent replied that length of stay increased because “people note [in the record] that [the] problem hasn’t been resolved.” One of the interesting observations made by centens using POMR was that physicians were less favorably inclined to accept POMR than other members of the treatment teams. Only 9 of the 36 centers (25%) reported that the attending medical staff liked POMR. The replies expressed this through such comments as, “Approve in principle, frequently find it hand to change their own [physician’s] way of doing things,” “Are somewhat resistive,” “It requires a higher level of medical acumen; this affects some staff who don’t know what they are doing very well.” We wondered if the acceptance or rejection of POMR was related to the theoretical orientation of the institution. The 147 respondents indicated their treatment philosophy on a spectrum from purely psychoanalytic to predominantly physical therapies. There was no difference among groups with different theoretical orientations in terms of use of POMR. Howeven, the more psychodynamically oriented centers expressed more difficulties in adapting POMR to their own use, e.g., “They produce stereotyped records that fail to yield dynamic appreciation of the patient’s problems.” Aside from difficulties in adjusting individual thenapeutic styles to a new system, many criticisms of POMR were directed at the extra clerical work involved, e.g. : “Some versions contain a great deal of information that may prove useless, and progress notes may require a good deal of paper shuffling.” “The POMR require about twice as much writing by the doctors; we have enough trouble getting records written without doubling the work; what we need is a system that requires less writing.”
DISCUSSION
After service,
six
months
our
impression
of using is that
POMR they
on our do not
add
inpatient much
in
terms of actual patient cane, despite the fact that they result in better organization of the records. Some people at Malcolm Bliss feel that POMR discourage
COMMUNICATIONS
charting because of their seemingly formalistic style, but the notes that are written within this system tend to be more complete and informative. It appears that there is considerable interest among community mental health centers in problem-oriented medical records. One-half of the 147 centers who answered our questionnaire said they would be using this system by the end of 1975, and one-sixth were undecided. Even though one-third had no plans to introduce POMR, almost all requested the results of this survey, and many asked for practical references With the increasing need for treatment evaluation and accountability (13), POMR may gain additional significance; they could become mandatory for all mental health centers. Criticisms leveled at this system point out the difficulties individual therapists have in defining “problems.” Obviously, the definition of a problem in psychiatry is a delicate task requiring a high degree of skill and experience. A considerable amount of reeducation and in-service training will be required to avoid overinclusion or particularization. REFERENCES I. Weed LL: Medical records that guide and teach. N EngI I Med 270:593-600, 652-657, 1968 2. Hurst JW: Ten reasons why Weed is right. N EngI J Med 284:51-52, 1971 3. Hurst JW, Walker HK (eds): The Problem-Oriented System. New York. Medcom Press, 1972 4. Hurst JW, Walker HK, Hall WD: More reasons why Weed is right. N EngI J Med 288:629-630, 1973 5.
Gokinnger
believer. 6. Fletcher
records.
SE: The problem-oriented N EngI J Med 288:606-608, RH: Auditing problem-oriented
N EngI J Med 290:829-833,
record, 1973 records
a critique
from a
and traditional
1974
7. Hayes-Roth F, Longbaugh R, Ryback R: The problem-oriented medical record and psychiatry. BrJ Psychiatry 121:27-34, 1972 8. Novello JR: The problem-oriented record in psychiatry. J Nerv
Ment Dis 156:349-353,
1973
9. Giladas AJ: The problem-oriented record in a psychiatric hospital. Hosp Community Psychiatry 23:336-339, 1972 10. Grant RL: Enthusiasm no substitute for hard work. Int J Psychiatry 11:366-373, 1973 I I . Spitzer RL: Problem oriented records: some reservations. mt I Psychiatry 11:376-379, 1973 12. National Institute of Mental Health: Directory of Federally
Funded NIMH,
Community Sept 1973
13. Lipp M: Quality control system. Int J Psychiatry
Am
Mental
Health
in psychiatry I I :355-365,
J Psychiatry
133:3,
Centers.
Rockville,
and the problem 380-381,1973
March
1976
Md,
oriented
341
COMMUNICATIONS
9. Bass UF,
Brown
BS: Methadone
maintenance
detoxification: a comparison of retention teristics. Int J Addict 8:889-895, 1973
The
Use
Mental
and client
charac-
10. Aron WS, Daily D: Short- and long-term therapeutic nities: a follow-up and cost effectiveness comparison.
Medical
Records
in Community
Centers
M. VICKAR,
M.D.,
AND MARIJAN
HERJANIC,
M.D.
in other The authors’ questionnaire survey of147 community mental health centers revealed that 36 (24%) were using problem-oriented medical records (POMR), 34 (23%) planned to use them, 23 (16%) were uncertain, and54 (37%) had not considered using them. According to the responses ofcenters that were using POMR and the authors’ experience, the advantages of POMR in psychiatry are similar to their advantages in other specialties, and the difficulties in implementing this system are related to the definition of “problems.”
WEED’S
commumt J Ad-
dict9:619-636, 1974
of Problem-Oriented Health
BY GARRY
and methadone
rates
of problem-oriented
INTRODUCTION
medical
psychiatric
facilities
and
undertook
a survey
of other mental health centers. Using the September 1973 Directory ofFederally Funded Community Mental Health
Centers
(12),
we
sent
questionnaires
to all
community mental health centers in operation at the end of August 1974. We inquired about the adoption, acceptance, and advantages of POMR.1
FINDINGS
Three hundred out in August swered. Eleven
thirty-four questionnaires 1974; 158 (47%) were replies had to be dropped
lations
they
because
were
were sent returned anfrom calcu-
incomplete.
about the use of POMR in psychiatric practice than in other medical specialties. Considering the many advantages claimed for POMR in psychiatry (7), we were sunprised to find only an occasional report of their use in
Thirty-six of the 147 centers (24%) were using POMR. These centers were apparently distributed randomly throughout the United States. Of these 36 centens, 19 used POMR for both inpatients and outpatients, 8 for inpatients only, and 9 for outpatients only. The average duration ofuse was about 12 months (1 center claimed to have been using a modified form of POMR for 27 years). Thirty-four of the 147 centers (23%) planned to irnplement POMR, and 23 of the centers (16%) were Uncertain. The remaining 54 centers (37%) had not con-
this
sidered
records
ond
(POMR)
keeping
(1)
in many
has
led
medical
to a reevaluation
centers.
Following
adoption of this system, publications appeared ing POMR and encouraging their acceptance cialties of medicine (2-4). More recently
been
some
uation
of
field
questioning this
new
and approach
(8, 9). It may
be that
attempts (5,
of nec-
at critical 6).
Less
psychiatrists
the
endorsin all spethere has is
have
evalknown
bene-
fited from the experience of colleagues in other branches of medicine (10, 11) and approached the subject with caution. The POMR was first used in the inpatient service of Malcolm Bliss Mental Health Center, St. Louis, Mo., on July 1 , 1974. We wondered about the extent ofits use
so made collection
improved Dr. Vickar is Instructor Professor of Psychiatry, cine, 1420 Grattan St., Assistant Superintendent, Louis, Mo.
340
Am
in Psychiatry and Dr. Henjanic is Associate Washington University School of McdiSt. Louis, Mo. 63104. Dr. Henjanic is also Malcolm Bliss Mental Health Center, St.
J Psychiatry
133:3,
March
1976
using
POMR.
Twenty-four of the 36 centers using POMR (67%) agreed that their use improved their record keeping in terms of organization, readability, and identification of problem areas. The better organization al-
using ‘Copies quest.
for easier supervision for research purposes.
patient POMR of the
had
care, mixed
questionnaire
the
of residents and data When asked about
36 respondents
reactions, are available
but from
who 23 (64%) Dr.
Vickar
were beon re-
BRIEF
lieved that patients benefited from the more consistent approach in documentation. Thirteen (36%) were not aware ofa change in length ofstay, but one respondent replied that length of stay increased because “people note [in the record] that [the] problem hasn’t been resolved.” One of the interesting observations made by centens using POMR was that physicians were less favorably inclined to accept POMR than other members of the treatment teams. Only 9 of the 36 centers (25%) reported that the attending medical staff liked POMR. The replies expressed this through such comments as, “Approve in principle, frequently find it hand to change their own [physician’s] way of doing things,” “Are somewhat resistive,” “It requires a higher level of medical acumen; this affects some staff who don’t know what they are doing very well.” We wondered if the acceptance or rejection of POMR was related to the theoretical orientation of the institution. The 147 respondents indicated their treatment philosophy on a spectrum from purely psychoanalytic to predominantly physical therapies. There was no difference among groups with different theoretical orientations in terms of use of POMR. Howeven, the more psychodynamically oriented centers expressed more difficulties in adapting POMR to their own use, e.g., “They produce stereotyped records that fail to yield dynamic appreciation of the patient’s problems.” Aside from difficulties in adjusting individual thenapeutic styles to a new system, many criticisms of POMR were directed at the extra clerical work involved, e.g. : “Some versions contain a great deal of information that may prove useless, and progress notes may require a good deal of paper shuffling.” “The POMR require about twice as much writing by the doctors; we have enough trouble getting records written without doubling the work; what we need is a system that requires less writing.”
DISCUSSION
After service,
six
months
our
impression
of using is that
POMR they
on our do not
add
inpatient much
in
terms of actual patient cane, despite the fact that they result in better organization of the records. Some people at Malcolm Bliss feel that POMR discourage
COMMUNICATIONS
charting because of their seemingly formalistic style, but the notes that are written within this system tend to be more complete and informative. It appears that there is considerable interest among community mental health centers in problem-oriented medical records. One-half of the 147 centers who answered our questionnaire said they would be using this system by the end of 1975, and one-sixth were undecided. Even though one-third had no plans to introduce POMR, almost all requested the results of this survey, and many asked for practical references With the increasing need for treatment evaluation and accountability (13), POMR may gain additional significance; they could become mandatory for all mental health centers. Criticisms leveled at this system point out the difficulties individual therapists have in defining “problems.” Obviously, the definition of a problem in psychiatry is a delicate task requiring a high degree of skill and experience. A considerable amount of reeducation and in-service training will be required to avoid overinclusion or particularization. REFERENCES I. Weed LL: Medical records that guide and teach. N EngI I Med 270:593-600, 652-657, 1968 2. Hurst JW: Ten reasons why Weed is right. N EngI J Med 284:51-52, 1971 3. Hurst JW, Walker HK (eds): The Problem-Oriented System. New York. Medcom Press, 1972 4. Hurst JW, Walker HK, Hall WD: More reasons why Weed is right. N EngI J Med 288:629-630, 1973 5.
Gokinnger
believer. 6. Fletcher
records.
SE: The problem-oriented N EngI J Med 288:606-608, RH: Auditing problem-oriented
N EngI J Med 290:829-833,
record, 1973 records
a critique
from a
and traditional
1974
7. Hayes-Roth F, Longbaugh R, Ryback R: The problem-oriented medical record and psychiatry. BrJ Psychiatry 121:27-34, 1972 8. Novello JR: The problem-oriented record in psychiatry. J Nerv
Ment Dis 156:349-353,
1973
9. Giladas AJ: The problem-oriented record in a psychiatric hospital. Hosp Community Psychiatry 23:336-339, 1972 10. Grant RL: Enthusiasm no substitute for hard work. Int J Psychiatry 11:366-373, 1973 I I . Spitzer RL: Problem oriented records: some reservations. mt I Psychiatry 11:376-379, 1973 12. National Institute of Mental Health: Directory of Federally
Funded NIMH,
Community Sept 1973
13. Lipp M: Quality control system. Int J Psychiatry
Am
Mental
Health
in psychiatry I I :355-365,
J Psychiatry
133:3,
Centers.
Rockville,
and the problem 380-381,1973
March
1976
Md,
oriented
341
