Contextualisation of Clinical Information from Fragmented Health Records

摘要

Traditionally health records have a source-oriented structure, as opposed to a clinically logical structure. The aim of the current study is to record and depict the clinically logical information structure built by doctors as part of their contextualisation of clinical information, to compare this structure to that of a given health record, and to assess whether a structural difference may have negative consequences. Eight doctors in a medical department were observed during contextualisation of clinical information. The method of observation included simultaneous interviews and with the technique used it was possible to depict the clinically logical information structure and compare it to the structure of the health record. The doctors' information structure was found to differ widely from the structure of the health record, causing split-attention and stress. It is concluded that the present health record is suboptimal. Further research in information support based on clinically logical structure is recommended.