A qualitative investigation into clinical documentation: why do clinicians document the way they do?
Author(s)
Rowlands, Stella
Tariq, Amina
Coverdale, Steven
Walker, Sue
Wood, Maryann
Griffith University Author(s)
Year published
2020
Metadata
Show full item recordAbstract
BACKGROUND: Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. OBJECTIVE: To gain an in-depth understanding of clinician ...
View more >BACKGROUND: Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. OBJECTIVE: To gain an in-depth understanding of clinician documentation practices. METHOD: A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. RESULTS: Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. CONCLUSION: Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format.
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View more >BACKGROUND: Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. OBJECTIVE: To gain an in-depth understanding of clinician documentation practices. METHOD: A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. RESULTS: Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. CONCLUSION: Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format.
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Journal Title
Health Inf Manag
Note
This publication has been entered in Griffith Research Online as an advanced online version.
Subject
Health services and systems
Public health
communication
documentation
electronic health records
health information management
hospital records