title: [Basic registration of risk factors in medical records. Malnutrition, overweight, physical inactivity, smoking and alcohol].
abstract: 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.
authors.affiliation: Bispebjerg Hospital, Klinisk Enhed for Sygdomsforebyggelse/WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals, København NV. hanne.tonnesen@bbh.regionh.dk
authors.forename: Hanne
authors.initials: H
authors.lastname: Tønnesen
authors.forename: Nina
authors.initials: N
authors.lastname: Roswall
authors.forename: Mette Dissing
authors.initials: MD
authors.lastname: Odgaard
authors.forename: Klaus Michael
authors.initials: KM
authors.lastname: Pedersen
authors.forename: Karen Lindorff
authors.initials: KL
authors.lastname: Larsen
authors.forename: Bjørn
authors.initials: B
authors.lastname: Mathiassen
authors.forename: Richard
authors.initials: R
authors.lastname: Farlie
authors.forename: Anders
authors.initials: A
authors.lastname: Elbirk
authors.forename: Mogens
authors.initials: M
authors.lastname: Hüttel
authors.forename: Lasse
authors.initials: L
authors.lastname: Danborg
authors.forename: Vibeke
authors.initials: V
authors.lastname: Vestermark
authors.forename: Anette Lykke
authors.initials: AL
authors.lastname: Petri
authors.forename: Niels
authors.initials: N
authors.lastname: Ebbehøj
authors.forename: Marianne
authors.initials: M
authors.lastname: Frederiksen
authors.forename: Tatjana
authors.initials: T
authors.lastname: Hejgaard
mesh_terms: 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