SummaryClinical formulation was introduced in its present form a little over 30 years ago and is, in essence, a concise summary of the origins and nature of a person's problems, together with opinion on what may go wrong in the future and what steps should be taken to improve matters. In our article we discuss how, in recent times, the task of preparing a clinical formulation has rightly become a multidisciplinary exercise involving the whole clinical team and, even more important, that nowadays the patient – the subject of the clinical formulation – together with their carers should also be actively involved in the process and feel some ownership of the conclusions and decisions. In addition, we compare these developments in clinical formulation with similar developments, arising for the same reasons, in clinical teaching and education.Learning Objectives• Understand the core principles of formulation• Know how to prepare a formulation within a clinical team• Understand the role that formulation plays in the effective management of patients
This article begins with a summary of the trend toward a person-based health record, and the need to integrate data from a variety of sources to achieve this. A project is described that demonstrated problems with the structure of nursing care plans. These problems affected the ability to integrate care plan data into a clinical database capable of analysis to link control of process with clinical outcome. A second project is described that focused on the development of data sets holding higher-level descriptions suitable for the maintenance of a person-based record, but at a summarized level and with no clinical detail. Finally, a prototype care planning system is described that, while maintaining the data required by the Nursing Process, was more flexibly structured to support analysis and hierarchical levels of description.
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