Medicina Interna: Acesso Aberto
Acesso livre

Abstrato

Documentation of Patient Problems and Strengths in Electronic Health Records

Grace Gao, Madeleine Kerr, Ruth Lindquist and Karen Monsen 

Background: A whole-person representation captures not only patient problems but also patient strengths. To better understand and inform practice of person-centered care and documentation using a whole-person representation, a critical review of literature was conducted of the current state of patient problems and strengths documentation in electronic health records.
Methods: The informatics model of Data, Information, Knowledge and Wisdom is employed to develop this critical review. Two scientific databases were used to conduct a systematic search: CINAHL and Ovid Medline with the following search terms: strength*, problem*, whole person, wellbeing or well-being, electronic health record*, personal health record*, EHR*, and PHR*. 602 articles were returned. All articles were screened through review of titles, abstracts, or full texts. 24 articles were selected for this review.
Results: Four themes have emerged from this critical review. They are individual or cross-institutional use of problem-oriented EHRs, extension of problem-based EHRs with other integration, patient-centered integration of the problem-oriented EHR build, and construction of a whole-person representation to include strengths in the EHR documentation. The vast majority of articles focus on problem-based diagnoses and practices. Early reports of strengths documentation were found using a standardized interface terminology and ontology, the Omaha System. Results of two studies demonstrated the feasibility of using the Omaha System for whole-person documentation to capture perception of both problems and strengths.
Conclusion: Clinical information in EHRs is typically structured by problem-based diagnoses; however, there is emerging documentation of formalized strengths attributes using the Omaha System, which may promote a holistic approach to clinical practice and documentation using a person-centered, strength-based ontology.