Sammanfattning
Documentation in the patient record must be systematic and rigorous. However, each health care
profession documents parts of the electronic health record (EHR) separately. This system can lead to
double documentation. The aim of the study was to describe the amount of double documentation in
health records for in-patients. A retrospective descriptive review of 30 records for in-patients
diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed
during the stay in hospital and in or between all professions reviewed. In total, 822 instances of
double documentation were found. The EHRs available today are not designed to monitor processes.
Instead, they follow each health profession, which can lead to double documentation. It would be
desirable to develop an EHR from a process perspective and not a record per profession.