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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. Linköping University, Faculty of Medicine 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: 2017-05-02

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Törnvall, Eva
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Research & Development Unit in Local Health CareDepartment of Medical and Health SciencesFaculty of Medicine and Health Sciences
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CiteExportLink to record
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Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf