Information Management In Psychiatry

Creation of a medical record information system has at its’ heart a database. The data fields in this database reflect the clinical content of the medical record. As a first step toward developing a psychiatric clinical information system we have systematically reviewed every document in the psychiatric medical record at the Resnick Neuropsychiatric Hospital at UCLA. Due to this review we have developed templates for our psychiatric medical records which include “fill in the blanks” and “check boxes” to prompt the evaluator. These forms are envisioned as the “front-end” or user interface of a psychiatric record database. This standardized format with checkboxes and fill in the blank sections facilitates the planning for the creation of a psychiatric clinical information database containing the key components of the medical record. These forms ensure relevant information is obtained and are useful in structuring a comprehensive psychiatric evaluation.