Towards a standard documentation for behavioral health

The authors present a suggested standardized documentation record that they hope will eventually achieve wider usage, especially in private practice settings. They first discuss current problems caused by a lack of standard documentation and the influence of managed care and risk management on record-keeping requirements. The advantages that can result from using a standardized documentation system are then reviewed, including the delivery of better organized and integrated care, improved presentations to case managers, enhanced communication among clinicians, and reduced malpractice exposure. The authors then present one component of their proposed modular documentation system, the Initial Evaluation Form, and give a detailed annotation concerning how it should be used. Readers are requested to try the form and provide feedback to improve it. Additional components of this proposed documentation system will be presented in upcoming articles.

Duke Scholars

Author Allan Krekeler Chrisman Psychiatry, Child & Family Mental Health & Community Psychia ...