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Psychosocial health information in free text notes of Swedish children's health records
Högskolan i Jönköping, Hälsohögskolan, HHJ. CHILD.
Högskolan i Jönköping, Hälsohögskolan, HHJ. CHILD. Högskolan i Jönköping, Högskolan för lärande och kommunikation, HLK, CHILD.ORCID-id: 0000-0001-9597-039X
University of North Carolina at Chapel Hill, NC, USA.
Högskolan i Jönköping, Hälsohögskolan, The Jönköping Academy for Improvement of Health and Welfare. Högskolan i Jönköping, Hälsohögskolan, HHJ. Kvalitetsförbättring och ledarskap inom hälsa och välfärd.
Visa övriga samt affilieringar
2013 (Engelska)Ingår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 27, nr 3, s. 616-623Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: High-quality documentation of children’s health is an important priority in health care given trends of declining mental health and reduced well-being in children. There is a lack of information concerning psychosocial health in the standardized part of the national health record in the Child Health Service and the School Health Service in Sweden. Further, little is known if the free text notes in the health record, besides information on physical health, also include information on children’s psychosocial health. The aim of this study was to describe what is recorded concerning children’s health and development in free text notes.

Methods: The study was based on a retrospective analysis of text using an inductive approach for qualitative analyses of content.

Results: The analysis of the free text notes in the health records yielded seven categories: development, family, health problems, living habits, medical issues, preschool/school and leisure, and well-being. The categories mainly covered psychosocial aspects of health and were not only about health and development problems of the child but also what was covered during the visits. The information was unevenly distributed across the ages. A stronger focus on the youngest age groups within a family and preschool setting is needed. There was novel information in the free text notes such as pain, general health, emotions, mother’s mental health and leisure activities, which was not covered in the standardized part of the health records.

Conclusion: The free text notes mainly reflected a psychosocial perspective on health. The findings of this study suggest that requesting more information on children’s psychosocial health in the standardized part of the health records could contribute to more comprehensive and informative health records in the Child health Service and the School Health Service in Sweden.

Ort, förlag, år, upplaga, sidor
2013. Vol. 27, nr 3, s. 616-623
Nyckelord [en]
health, Child Health Service, School Health Service, health records, psychosocial health, Sweden
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
URN: urn:nbn:se:hj:diva-19374DOI: 10.1111/j.1471-6712.2012.01059.xISI: 000321625800015PubMedID: 22891972Scopus ID: 2-s2.0-84880310098Lokalt ID: HHJCHILDIS, HHJKvalitetISOAI: oai:DiVA.org:hj-19374DiVA, id: diva2:550857
Tillgänglig från: 2012-09-08 Skapad: 2012-09-08 Senast uppdaterad: 2018-10-22Bibliografiskt granskad
Ingår i avhandling
1. Documentation in Child and School Health services: Mapping health information from a biopsychosocial perspective using the ICF-CY
Öppna denna publikation i ny flik eller fönster >>Documentation in Child and School Health services: Mapping health information from a biopsychosocial perspective using the ICF-CY
2012 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
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.

Ort, förlag, år, upplaga, sidor
School of Health Sciences Jönköping University, 2012. s. 77
Serie
Dissertation Series. School of Health Sciences, ISSN 1654-3602 ; 29
Nationell ämneskategori
Omvårdnad
Identifikatorer
urn:nbn:se:hj:diva-17948 (URN)978-91-85835-28-7 (ISBN)
Disputation
2012-04-27, Forum Humanum, Hälsohögskolan, 551 11, Jönköping, 13:00
Opponent
Handledare
Tillgänglig från: 2012-04-17 Skapad: 2012-04-17 Senast uppdaterad: 2012-09-12Bibliografiskt granskad

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Ståhl, YlvaGranlund, MatsEnskär, Karin

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Ståhl, YlvaGranlund, MatsAndersson-Gäre, BoelEnskär, Karin
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HHJ. CHILDHLK, CHILDThe Jönköping Academy for Improvement of Health and WelfareHHJ. Kvalitetsförbättring och ledarskap inom hälsa och välfärd
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Scandinavian Journal of Caring Sciences
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi

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