부산대학교 도서관

Introduction: Patient care and treatment is usually documented in a double-stranded patient record, i.e. a record with separate sections for different health professionals, which reduces the possibility of getting a comprehensive view of the patient's case. Therefore, the Pediatric Department chose to implement a single-stranded medical record. Material and methods: Development and evaluation of the new record was based on standards formulated during interdisciplinary audits. Eighteen months after its implementation, the record was evaluated by interdisciplinary audits and questionnaires. All health professionals employed at the department were included. Data from the questionnaires were analyzed descriptively and summaries of the audits were analyzed using an anthropological method. Results: A total of 149 staff members (96%) responded to the questionnaire and eight records were evaluated by audits at which a total of 63 interdisciplinary clinicians participated. The evaluation concluded that overlapping documentation was reduced considerably, 97% of the staff members reported that their documentation was being read by their colleagues and 84% reported that the patient record gave them a good general view of the patients' case apart from complicated patient cases and long lasting admissions. Conclusion: The single-stranded interdisciplinary patient record reduces documentation overlap. The record facilitates overview and continuity in short-term patient cases. The participating staff became acquainted with and now uses the information documented by other health professionals.