Treatment planning: implications for structure of the CPR

The work of developing a specification for treatment and care planning software reveals lacunae in current structural conceptualizations of the computer-based patient record (CPR). A written treatment plan is ubiquitous in psychiatric settings, highly structured, and in theory, ideally suited to computerization. Treatment and care planning are also prevalent in nursing, rehabilitation, and long-term care. Treatment plans justify treatment with clinical data, and document goals, methods, and treatment outcomes. Implementing computer-based planning has been more difficult than first thought because present CPR systems do not support data schemes suited for integrating treatment plans with the general patient record. The CPR for general medical care will advance when it can support a treatment plan. Gaps in current CPR design exposed by requirements analysis for a multidisciplinary, team-based treatment planning system are identified.