[New documentation routines in psychiatry in Västerbotten: unified structure for better quality of care]

During recent decades psychiatric health care has become increasingly complex due to substantial clinical improvements and to the growing need of integrating psychiatric services with other health and welfare services in the community. The traditional psychiatric record format is incompatible both with these requirements and with the practical advantages and difficulties of modern computer technology. In a collaborative effort involving most professional categories at three psychiatric units in the county of Västerbotten in northern Sweden, a new structured format for medical records was developed. The basic feature is a structured summary of background factors, social situation, drug habits, and general health, which is reviewed and updated as necessary. The psychiatric condition is described in some detail, including onset and course, symptomatology, personality factors, diagnosis, treatment results, suicidality, etc. Day to day treatment is outlined in in- and out-patient treatment plans, which are evaluated and revised at regular intervals. The new record format, which is used by all categories of health care professionals, is intended to promote goal-directed treatment and professional collaboration, and is easily adapted to computer technology.