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Poster Abstracts

Digital documentation: “Everyone should know what to do”

Authors:

Julie Duval Jensen ,

Department Of Public Health, Aarhus University, Denmark, DK
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Loni Ledderer,

Department Of Public Health, Aarhus University, Denmark, DK
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Raymond Kolbæk,

Center for Research in Clinical Nursing Department of Nursing, VIA University College, DK
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Kirsten Beedholm

Department Of Public Health, Aarhus University, Denmark, DK
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Abstract

Introduction: In Denmark, digitalization of the municipal electronic health records has resulted in a nationwide standardization of the documentation process; based on the assumption that digitalization is a solution to problems with continuity of patient care. In these years, health care professionals translate strategies of digital documentation into professional practice in healthcare organizations. This study aims to investigate how ideas of digital documentation translate into routine professional practice and how it takes part in the construction of health care practice.

Theory and Methods: From an organizational institutional perspective, the health professionals are understood as institutional actors, who interpret, transform and adapt abstract ideas of the digital documentation into concrete routine healthcare practice. The study is conducted as a qualitative single-case study. A municipality in Denmark with a typical organizational structure of home care is chosen as a typical case. 

Empirical data is generated from instructional material and other documents related to the local documentation practice, observation of home care visits, and interviews with health professionals. During 124 hours of field observations, 15 health professionals were followed during home care visits and staff meetings. So far, 15 health professionals participated in semi-structured interviews.

Results: The study is ongoing and preliminary analysis shows that the digital documentation takes on an infrastructure that is expected to support efficiency in planning and work procedures. The EHR becomes an extensive system, utilized to plan health care services by the minute. Furthermore, documentation is structured by extensive use of predefined classifications, dividing health care into small bits of concrete tasks, defined by citizen categories, time, specific health service, and type of professional roles. As such, the idea of digital documentation is operationalized through an EHR system designed to ensure efficiency through strict work procedures and concrete tasks.

Health professionals appear to translate the idea of digital documentation according to a normative institutional logic corresponding to a historical conditioned view that written information in the documentation system is supporting safety and quality in health care services. Health professionals document, because they believe that information leads to the citizen feeling safe and trusting the health professional, as digital documentation ensures ‘that everyone knows what to do.’ Moreover, health professionals turn to digital documentation when in doubt of the proper action, and base decisions on information from the digital documentation to prevent errors. 

Discussion: Digital documentation becomes an arena for paradoxes when the infrastructure on the one side draws upon an efficiency logic dividing information and services into small bits, and functions as a managerial tool for planning and delivering services. On the other side, digital documentation functions as an important center for sharing knowledge of professional actions when delivering services to elderly citizens with multiple needs.

Conclusion: The preliminary analysis indicates a paradox when the health professionals translate the idea of digital documentation according to professional norms and values centering on the citizen’s experience of health care and patient safety and the EHR is operationalized corresponding to a efficiency logic.

 

How to Cite: Duval Jensen J, Ledderer L, Kolbæk R, Beedholm K. Digital documentation: “Everyone should know what to do”. International Journal of Integrated Care. 2022;22(S3):292. DOI: http://doi.org/10.5334/ijic.ICIC22348
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Published on 04 Nov 2022.

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