Summary
Objective: The purpose of this study was to describe and evaluate patient care documentation
by hospital physicians in EHRs and especially the use of national headings and classifications
in these documentations Material and Methods: The initial material consisted of a random sample of 3,481 medical narratives documented
in EHRs during the period 2004-2005 in one department of a Finnish central hospital.
The final material comprised a subset of 1,974 medical records with a focus on consultation
requests and consultation responses by two specialist groups from 871 patients. This
electronic documentation was analyzed using deductive content analyses and descriptive
statistics.
Results: The physicians documented patient care in EHRs principally as narrative text. The
medical narratives recorded by specialists were structured with headings in less than
half of the patient cases. Consultation responses in general were more often structured
with headings than consultation requests. The use of classifications was otherwise
insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation
responses by both medical specialties.
Conclusion: There is an obvious need to improve the structuring of narrative text with national
headings and classifications. According to the findings of this study, reason for
care, patient history, health status, follow-up care plan and diagnosis are meaningful
headings in physicians’ documentation. The existing list of headings needs to be analyzed
within a consistent unified terminology system as a basis for further development.
Adhering to headings and classifications in EHR documentation enables patient data
to be shared and aggregated. The secondary use of data is expected to improve care
management and quality of care.
Keywords
Electronic health records - medical informatics - documentation - classification
