title: How are allied health notes used for inpatient care and clinical decision-making? A qualitative exploration of the views of doctors, nurses and allied health professionals.
abstract: BACKGROUND
  Inpatient care is dependent upon the effective transfer of clinical information across multiple professions. However, documented patient clinical information generated by different professions is not always successfully transferred between them. One obstacle to successful information transfer may be the reader's perception of the information, which is framed in a particular professional context, rather than the information per se.
  
  
  OBJECTIVE
  The aim of this research was to investigate how different health professionals perceive allied health documentation and to investigate how clinicians of all experience levels across medicine, nursing and allied health perceive and use allied health notes to inform their decision-making and treatment of patients.
  
  
  METHODS
  The study used a qualitative approach. A total of 53 speech pathologists, nurses, doctors, occupational therapists, dieticians and social workers (8 males; 43 females) from an Australian regional tertiary hospital participated in eleven single discipline focus groups, conducted over 4 months in 2012. Discussions were recorded and transcribed verbatim and coded into themes by content analysis.
  
  
  RESULTS
  Six themes contributing to the efficacy of clinical information transference emerged from the data: day-to-day care, patient function, discharge and discharge planning, impact of busy workloads, format and structure of allied health documentation and a holistic approach to patient care.
  
  
  CONCLUSIONS
  Other professions read and used allied health notes albeit with differences in focus and need. Readers searched for specific pieces of information to answer their own questions and professional needs, in a process akin to purposive sampling. Staff used allied health notes to explore specific aspects of patient function but did not obtain a holistic picture.
  
  
  CONCLUSIONS
  Improving both the relationship between the various health professions and interpretation of other professions' documented clinical information may reduce the frequency of communication errors, thereby improving patient care.
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.|2 College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.
authors: Tilley
authors: T
authors: Pain
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.|2 College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.
authors: Gail
authors: G
authors: Kingston
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.
authors: Janet
authors: J
authors: Askern
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.
authors: Rebecca
authors: R
authors: Smith
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.
authors: Sandra
authors: S
authors: Phillips
authors: 1 Queensland Health, The Townsville Hospital, Townsville, Queensland, Australia.
authors: Leanne
authors: L
authors: Bell
mesh_terms: D000328:Adult; D000488:Allied Health Personnel / Q000523:psychology*; D000066491:Clinical Decision-Making; D004282:Documentation; D005260:Female; D017144:Focus Groups; D006801:Humans; D007297:Inpatients; D033183:Interdisciplinary Communication; D008297:Male; D009741:Nursing Staff, Hospital / Q000523:psychology*; D010351:Patient Discharge; D010820:Physicians / Q000523:psychology*; D036301:Qualitative Research; D016526:Workload
keywords: allied health occupations; clinical decision-making; clinical documentation; communication; electronic health records; health information management; inpatients; medical records; nursing records; physicians