An information system for clinical recording, administrative decision making, evaluation, and research

An information system suitable for clinical, administrative, and research uses is described. The source document is a modified problem-oriented record in which progress on each problem can be measured by a goal attainment scaling technique during therapy, at termination, and at follow-up. The model deals with the problem of how specific the goals should be by establishing two evaluation procedures. One procedure is based on predefined long-term general goals of therapy. The other procedure deals with therapist defined short-term goals and procedures.