Medical Records That Guide and Teach

Implementation of More Comprehensive Care through the medical record and the ComputerThe organization of the record described above forms a framework that easily accommodates psychiatric, social and demographic problems. Usually these are not documented and followed in an organized manner.Psychiatric ProblemsIn the practice of medicine for many physicians, nonorganic problems have been neither challenging nor interesting. Because of this they have never been listed — even though they easily could have been — with the physician using clear descriptive formulations such as "cries easily" or "family difficulties" if he could not use sophisticated psychiatric jargon. Until all . . .