liu.seSearch for publications in DiVA
Change search
ReferencesLink to record
Permanent link

Direct link
Double documentation in electronic health records
Region Halland, Halmstad University.
Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Department of Medical and Health Sciences.
Göteborgs universitet.
2016 (English)In: Nordic journal of nursing research, ISSN 2057-1585, Vol. 36, no 2, 88-94 p.Article in journal (Refereed) Published
Abstract [en]

Documentation in the patient record must be systematic and rigorous. However, each health care profession documents parts of the electronic health record (EHR) separately. This system can lead to double documentation. The aim of the study was to describe the amount of double documentation in health records for in-patients. A retrospective descriptive review of 30 records for in-patients diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed during the stay in hospital and in or between all professions reviewed. In total, 822 instances of double documentation were found. The EHRs available today are not designed to monitor processes. Instead, they follow each health profession, which can lead to double documentation. It would be desirable to develop an EHR from a process perspective and not a record per profession.

Place, publisher, year, edition, pages
Sage Publications, 2016. Vol. 36, no 2, 88-94 p.
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-125446DOI: 10.1177/2057158515625368OAI: oai:DiVA.org:liu-125446DiVA: diva2:906116
Available from: 2016-02-23 Created: 2016-02-23 Last updated: 2016-08-19

Open Access in DiVA

No full text

Other links

Publisher's full text

Search in DiVA

By author/editor
Törnvall, Eva
By organisation
Research & Development Unit in Local Health CareDepartment of Medical and Health Sciences
Health Care Service and Management, Health Policy and Services and Health Economy

Search outside of DiVA

GoogleGoogle Scholar
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

Altmetric score

Total: 908 hits
ReferencesLink to record
Permanent link

Direct link