[Assessment of a single-stranded electronic patient record].
BACKGROUND
Patient care and treatment is usually documented in a double-stranded patient record, i.e. a record with separate sections for different health professionals, which reduces the possibility of getting a comprehensive view of the patient's case. Therefore, the Pediatric Department chose to implement a single-stranded medical record.


METHODS
Development and evaluation of the new record was based on standards formulated during interdisciplinary audits. Eighteen months after its implementation, the record was evaluated by interdisciplinary audits and questionnaires. All health professionals employed at the department were included. Data from the questionnaires were analyzed descriptively and summaries of the audits were analyzed using an anthropological method.


RESULTS
A total of 149 staff members (96%) responded to the questionnaire and eight records were evaluated by audits at which a total of 63 interdisciplinary clinicians participated. The evaluation concluded that overlapping documentation was reduced considerably, 97% of the staff members reported that their documentation was being read by their colleagues and 84% reported that the patient record gave them a good general view of the patients' case apart from complicated patient cases and long lasting admissions.


CONCLUSIONS
The single-stranded interdisciplinary patient record reduces documentation overlap. The record facilitates overview and continuity in short-term patient cases. The participating staff became acquainted with and now uses the information documented by other health professionals.
Nørgaard
Betty
B
Betty.Noergaard@fks.regionsyddanmark.dk
Ammentorp
Jette
J
Kirketerp
Edel
E
Kofoed
Poul-Erik
PE
D003266:Continuity of Patient Care / Q000592:standards; D006748:Hospital Departments; D006801:Humans; D033183:Interdisciplinary Communication; D008485:Medical Audit; D016347:Medical Records Systems, Computerized / Q000592:standards; D010372:Pediatrics; D010564:Personnel, Hospital; D011795:Surveys and Questionnaires