Appl Clin Inform 2014; 05(01): 153-168
DOI: 10.4338/ACI-2013-10-RA-0081
Research Article
Schattauer GmbH

A Qualitative Analysis Evaluating The Purposes And Practices Of Clinical Documentation

Y.-X. Ho
1  Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
,
C. S. Gadd
1  Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
,
K.L. Kohorst
2  Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
,
S.T. Rosenbloom
1  Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
3  Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
4  Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
› Author Affiliations
Further Information

Correspondence to:

S. Trent Rosenbloom
Eskind Biomedical Library
2209 Garland Ave.
Nashville, TN 37209
Phone: (615) 936–1541   
Fax: (615) 936–5900   

Publication History

received: 11 October 2013

accepted: 17 February 2013

Publication Date:
20 December 2017 (online)

 

Summary

Objectives: An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers’ and administrators’ perceptions about the purpose of clinical documentation and their own documentation practices.

Methods: We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects.

Results: We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stake-holders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data.

Conclusions: Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider’s busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.

Citation: Ho Y-X, Gadd CS, Kohorst KL, Rosenbloom ST. A qualitative analysis evaluating the purposes and practices of clinical documentation. Appl Clin Inf 2014; 5: 153–168 http://dx.doi.org/10.4338/ACI-2013-10-RA-0081


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Conflict of interest statement

The authors wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.


Correspondence to:

S. Trent Rosenbloom
Eskind Biomedical Library
2209 Garland Ave.
Nashville, TN 37209
Phone: (615) 936–1541   
Fax: (615) 936–5900