[Basic registration of risk factors in medical records. Malnutrition, overweight, physical inactivity, smoking and alcohol].
BACKGROUND
Lifestyle factors are important for clinical outcome. Systematic and early identification of these factors is important in order to offer relevant lifestyle intervention programmes. The objective was to evaluate whether basic registration of risk factors was understandable, applicable and sufficient in the clinical workday.


METHODS
Eleven clinical specialists participated from a broad range of departments. They performed identification and registration of malnutrition, overweight, physical inactivity, smoking and harmful alcohol consumption based on medical records from own departments (in total 2420 times). The specialists then evaluated the understanding, applicability and sufficiency (363 times). Their comments were noted.


RESULTS
Identification and registration was accomplished for 85% (0-100%) of the records. Except for two fields--"measurements of waist" and "other training programs"--the specialists found the basic registration understandable, applicable and sufficient. They lacked more details regarding stress-response in the information material and pointed out inconsistencies in the wording. Ten specialists found that the recommended clinical approach was possible to implement in the present routines.


CONCLUSIONS
Basic registration of lifestyle factors for adult patients is possible and clinical relevant. It is recommended that the Danish National Board of Health uses the results in future.
Tønnesen
Hanne
H
Bispebjerg Hospital, Klinisk Enhed for Sygdomsforebyggelse/WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals, København NV. hanne.tonnesen@bbh.regionh.dk
Roswall
Nina
N
Odgaard
Mette Dissing
MD
Pedersen
Klaus Michael
KM
Larsen
Karen Lindorff
KL
Mathiassen
Bjørn
B
Farlie
Richard
R
Elbirk
Anders
A
Hüttel
Mogens
M
Danborg
Lasse
L
Vestermark
Vibeke
V
Petri
Anette Lykke
AL
Ebbehøj
Niels
N
Frederiksen
Marianne
M
Hejgaard
Tatjana
T
D000328:Adult; D000428:Alcohol Drinking / Q000009:adverse effects / Q000517:prevention & control; D018450:Disease Progression; D015444:Exercise; D006801:Humans; D008019:Life Style; D044342:Malnutrition / Q000150:complications / Q000517:prevention & control; D016347:Medical Records Systems, Computerized / Q000592:standards; D050177:Overweight / Q000150:complications / Q000517:prevention & control; D010865:Pilot Projects; D012042:Registries; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D000074606:Smoking Prevention; D016896:Treatment Outcome