Department of Communication, University of Copenhagen, Copenhagen, Denmark.
Appl Clin Inform. 2021 Jan;12(1):27-33. doi: 10.1055/s-0040-1721013. Epub 2021 Jan 13.
Electronic health records (EHRs) are used in long-term care to document the patients' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals.
This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons.
The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]).
As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes.
Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients' condition and care are more prevalent and that issues about their consent are also common.
电子健康记录 (EHR) 用于长期护理，以记录患者的病情、用药和护理情况，从而支持护理人员之间的沟通并防止药物不良事件的发生。然而，长期护理中的 EHR 使用落后于医院中的 EHR 使用。此外，大多数 EHR 研究都集中在医院。
本研究描述了丹麦家庭护理和疗养院（这是长期护理的两个主要提供者）中与患者安全相关的文档记录风险的全国现状。这种现状为国家改进工作和国际比较提供了基础。
该研究基于丹麦患者安全局（Styrelsen for Patientsikkerhed [STPS]）对 893 次家庭护理和疗养院检查的报告。
多达 69%的受检查机构的记录存在不足，以至于 STPS 提出了要求（即机构有法律义务纠正的问题）或请求（即机构只需纠正的问题）。在收到要求的机构中（97%），几乎所有机构都存在关于患者病情和护理的记录问题，而在收到请求的机构中，大多数机构也存在这些问题（68%）。关于用药和护理同意的记录问题也很常见，但程度较轻。对患者安全的主要威胁是记录不完整。它涵盖了收到要求的机构中确定的记录问题的 72%；其余的风险涉及不一致（11%）、不存在（7%）、无法访问（5%）和不遵守（5%）的记录。家庭护理和疗养院的 EHR 文档不足问题相似。
丹麦长期护理中 EHR 文档记录不足是一个普遍存在的问题。虽然之前的研究主要关注 EHR 文档记录如何影响患者的用药，但本研究发现，关于患者病情和护理的记录问题更为普遍，关于其同意的问题也很常见。
