[The Frankfurt child and adolescent psychiatry documentation system--development and methodological principles with...

Measures to ascertain qualified work in child and adolescent psychiatry have become a great necessity, because of increasing financial pressures and changing laws. One basic measure should be a documentation system, which should include reliable basic data on the patient, standardized data of the psychopathological status and the latest version of the Multiaxial Classification System (MAS). The second chapter gives a brief overview of the historic development of documentation systems in psychiatry resp. child and adolescent psychiatry. Only very recently a trend toward a generally binding standardization has emerged. The third chapter describes the general methodological principles of clinical documentation. Finally, the Frankfurt Child and Adolescent Psychiatry Documentation System is presented, which has been developed between 1987 and 1993 at the Department of Child and Adolescent Psychiatry of the Frankfurt University School of Medicine. It is presently used in several german university hospitals. It consists of a six-part documentation sheet, a detailed glossary and a special computer program for data entry and data administration. It includes sociodemographic and anamnestic data, the psychopathological and somatic status, diagnostic assessment for the MAS and data on therapeutic measures and treatment outcome. The computer program, which can be used on any IBM-compatible PC, allows easy data input on the screen, controls distribution of case numbers, plausibility of important core data and ongoing security copies. The possible use of the documentation system for clinical quality assessment is discussed.