Elektronisk patientjournal riskerar patientsäkerheten. Granskning av journalanteckningar visar allvarliga
brister i dokumentation
Sammanfattning
Effective communication is a prerequisite for safe care. Today, electronic health records (EHR) are routinely used as a medium for communication. The objective of this study was to evaluate documentation routines to explore how these might support patient safety. Over ninety notes from 10 EHR’s made by nurses, physicians and assistant nurses were collected and thematically analyzed. One common observation was that text was often copied, sometimes with new information inserted. Headings were frequently chosen arbitrarily, and medical terms and abbreviations were abundant. Unsubstantiated statements were seen and sometimes important information was missing. The practice of copying text contributes to lengthy records and risk of information overload. Missing information and the use of medical language or abbreviations can be misunderstood by the target users of the EHR and possibly lead to patient safety risks. Our collective findings raise questions about whether records with these shortcomings support the provision of safe care. If not – for whom and what purpose are the records produced? We conclude that the documentation routines in EHR’s are in need of clarity of purpose and a general redesign if they are to better support communication in health care and to improve patient safety.