NCJ Number
44731
Date Published
1977
Length
81 pages
Annotation
THE DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF A CLIENT-ORIENTED CASE RECORD AT A PRIVATE RESIDENTIAL FACILITY FOR TROUBLED ADOLESCENT GIRLS IN BALTIMORE, MD., ARE DOCUMENTED.
Abstract
THE GOOD SHEPHERD CENTER PROVIDES RESIDENTIAL AND DAY TREATMENT SERVICES FOR SOME 120 GIRLS, MOST OF WHOM HAVE BEEN ADJUDICATED AS 'CHILDREN IN NEED OF SUPERVISION.' THE CENTER ADAPTED ITS PERSON-ORIENTED RECORD (POR) FROM THE PROBLEM-ORIENTED RECORD USED IN MEDICAL SETTINGS. THE COMPONENTS OF THE POR ARE THE FOLLOWING: THE DATA BASE, FROM WHICH PROBLEMS AND STRENGTHS ARE IDENTIFIED, GOALS ESTABLISHED, AND TREATMENT PLANS FORMULATED; THE PREEVALUATION CONFERENCE AND EVALUATION CONFERENCE TREATMENT PLANS; THE ASSESSMENT, WHICH DETAILS PROBLEMS AND STRENGTHS, PROGNOSES, CLINICAL DIAGNOSES, DISCHARGE PLANS, AND PROJECTED LENGTH OF STAY; PROGRESS NOTES AND REVIEWS; CASE ACTIVITY RECORDS; STATISTICAL RECORDS; AND UNUSUAL INCIDENT REPORTS. THE POR FORMAT FACILITATES TREATMENT, SUPERVISION, TRAINING, EVALUATION, AND ACCOUNTABILITY BY FOCUSING ON BOTH THE PROBLEMS AND STRENGTHS OF EACH CLIENT; BY CATEGORIZING ALL AREAS OF THE CLIENT'S LIFE (FAMILY, EDUCATION, BEHAVIOR, RELATIONSHIPS, DEVELOPMENT, EMOTIONAL, MEDICAL, AND LEGAL) AS THEY RELATE TO SERVICES OFFERED; BY HIGHLIGHTING GOALS AND PLANS; AND BY PROVIDING FOLLOWUP MATERIAL FOR SERVICE TEAM SELF-EVALUATION, FACILITY EVALUATION, SUPERVISION, AND TRAINING. DETAILS ARE PRESENTED OF THE DEVELOPMENT AND IMPLEMENTATION OF THE POR, PROCEDURES USED TO TRAIN STAFF AND TO EVALUATE THE POR, AND THE POR STATISTICAL RETRIEVAL SYSTEM. THE TRANSFERABILITY OF POR AND ITS ADAPTABILITY TO COMPUTERIZATION ARE DISCUSSED. THE EVALUATION, WHICH ENCOMPASSES THE FIRST 4 MONTHS OF POR IMPLEMENTATION, FOCUSES ON A COMPARISON OF THE FORMAT AND CONTENT OF THE POR WITH THAT OF THE FACILITY'S FORMER RECORDKEEPING SYSTEM. AN ANNOTATED BIBLIOGRAPHY AND A SAMPLE OF A COMPLETED POR ARE INCLUDED. FOR THE POR PROCEDURE MANUAL, SEE NCJ-44732.