Appl Clin Inform 2011; 02(02): 143-157
DOI: 10.4338/ACI-2010-12-RA-0073
Research Article
Schattauer GmbH

Use of Headings and Classifications by Physicians in Medical Narratives of EHRs

An evaluation study in a Finnish hospital
K. Häyrinen
1  University of Eastern Finland (Kuopio Campus), Department of Health and Social Management
,
K. Harno
1  University of Eastern Finland (Kuopio Campus), Department of Health and Social Management
,
P. Nykänen
2  University of Tampere, Department of Computer Sciences, Tampere, Finland
› Author Affiliations
Further Information

Publication History

Received: 16 December 2010

Accepted: 22 March 2011

Publication Date:
16 December 2017 (online)

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.