TOCRS—The therapy-oriented computer record system

A computerized system has been developed to provide treatment records for patients in the Duke Psychiatric Outpatient Clinic. Demographic, diagnostic, and therapeutic data are incorporated into a concise summary provided to the therapist for each patient visit. Variables were carefully chosen to capture essential therapeutic information while minimizing the burden of data entry on the therapist. Suggestions by the users have led to a number of modifications in the system, including the addition of special data-keeping functions for therapy groups and record generations of summary reports for clinicians and administrators. Essential information is gathered in a format well suited to analysis by standard computerized statistical techniques. Record keeping, in this fashion, provides an information base that describes the process of psychiatric treatment.