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Views on health information and perceptions of standardized electronic records among staff in Child and School Health Services
Jönköping University, School of Health and Welfare, HHJ. CHILD.
Jönköping University, School of Health and Welfare, HHJ. CHILD. Jönköping University, School of Education and Communication, HLK, CHILD.ORCID iD: 0000-0001-9597-039X
Jönköping University, School of Health and Welfare, HHJ. Quality improvements, innovations and leadership in health care and social work. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
Jönköping University, School of Health and Welfare, HHJ. CHILD.
2011 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 19, no 2, p. 201-208Article in journal (Refereed) Published
Abstract [en]

AIM: To investigate how nurses and physicians in the Child and School Health Services view the documentation and transfer of health information. Another aim concerns their perceptions of a nationally standardized electronic health record.

BACKGROUND: Problems of mental health among children and adolescents currently pose one of the greatest challenges facing all European countries. The continuity of health work demands that all health information follow the child's development, disregarding the organizational arrangement.

METHODS: The study was descriptive and comprised 484 questionnaires to nurses and physicians in the Child and School Health Services in Sweden.

RESULTS: More information about children's health was transferred than documented in the health record when children started school. This additional health information concerned psychosocial health and foremost family function. There was a consensus concerning the usefulness of a nationally standardized electronic health record, although there were group differences between nurses and physicians.

CONCLUSIONS: All information about children's health is not documented although the professional's positive perceptions to electronic health records may provide a basis to improve documentation.

IMPLICATIONS FOR NURSING MANAGEMENT: The results indicate challenges to develop a common language to document psychosocial issues necessary for providing a holistic view of children's health.

Place, publisher, year, edition, pages
John Wiley & Sons, 2011. Vol. 19, no 2, p. 201-208
Keywords [en]
Adolescent, Adult, Attitude of Health Personnel, Chi-Square Distribution, Child, Child Health Services/organization & administration, Communication, Documentation, Female, Health Care Surveys, Holistic Nursing, Humans, Male, Medical Records Systems, Computerized/organization & administration, Middle Aged, Nurses/psychology, Nursing Evaluation Research, Perception, Physicians/psychology, Program Development, Questionnaires, School Health Services/organization & administration, Sweden, Young Adult
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:hj:diva-17188DOI: 10.1111/j.1365-2834.2010.01201.xISI: 000288080500006PubMedID: 21375623Scopus ID: 2-s2.0-79952335045ISBN: 1365-2834 (Electronic) 0966-0429 (Linking) (print)OAI: oai:DiVA.org:hj-17188DiVA, id: diva2:478239
Available from: 2012-01-16 Created: 2012-01-16 Last updated: 2020-02-24Bibliographically approved
In thesis
1. Documentation in Child and School Health services: Mapping health information from a biopsychosocial perspective using the ICF-CY
Open this publication in new window or tab >>Documentation in Child and School Health services: Mapping health information from a biopsychosocial perspective using the ICF-CY
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to analyze whether the documentation in the Child Health Services (CHS) and School Health Services (SHS) reflects a holistic view on health as represented by a bio-psychosocial perspective.

The method used based on four studies, all with a descriptive design. Analyzed documents contained lists of health terms recommended to be included in the health record (HR) (I), requested information in health questionnaires (II) and the content of free text notes in health records (HRs) (III). A deductive approach was used on an item-by-item basis (I, II), and for the free text notes in HRs a qualitative content analysis with an inductive approach was chosen (III). Nurses’ and physicians’ views on documentation and electronic HR were analyzed with the help of a quantitative questionnaire design (IV).

Results showed that information on developed lists of health terms recommended to be included in an electronic version of the HR (I) could be linked to codes in the ICF-CY. The linked health terms were mainly focused on the body, i.e. a biological perspective on health. Several health terms linked to two or more codes, which indicate a need for more clarity in content descriptions. In the locally produced health questionnaires (Study II), for all age groups, a majority of the linked health items counted only once, and involved a psychosocial perspective on health. These health items were related to communication, psychosomatic symptoms and taking care of one’s health (II). The results in the free text notes in HRs (III) mainly focused on a psychosocial perspective on health and were represented across all age groups, but were unevenly distributed. There was new health information in the free text notes which had not been covered in the standardized  part  of  the  HRs. The respective staffs acknowledged that more health information than was documented in the HR was transferred between the CHS and SHS (IV). This information concerned foremost family function. The CHS and SHS had positive opinions regarding the possibilities of an electronic version of the HR.

Conclusions: The predominant medical content of lists of health terms was supplemented with health information related to psychosocial health in health questionnaires and in the free text notes in the HR. However, the focus was on the child as a person rather than a child within a family and preschool/school environment, and was strongly related to age groups. More information on children’s health than was recorded was transferred between and within the services. The utility of the ICF-CY as a tool has been confirmed, and indicates challenges to develop a common language to document more on psychosocial health.

Place, publisher, year, edition, pages
School of Health Sciences Jönköping University, 2012. p. 77
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 29
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-17948 (URN)978-91-85835-28-7 (ISBN)
Public defence
2012-04-27, Forum Humanum, Hälsohögskolan, 551 11, Jönköping, 13:00
Opponent
Supervisors
Available from: 2012-04-17 Created: 2012-04-17 Last updated: 2012-09-12Bibliographically approved

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Ståhl, YlvaGranlund, MatsAndersson-Gäre, BoelEnskär, Karin

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