Towards a multi-professional patient record - A study of the headings used in clinical practice

• This paper reports on the differences and similarities of headings used in patient records by Swedish health care professionals, nurses, occupational therapists, physiotherapists, dietitians, speech therapists, medical social workers and general practitioners. The background to the study is a national project where representatives from the different health care professions have worked together for two years in an effort to develop a multi-professional database of terms for the health care sector. The study reports on an analysis of the existing multi-professional lists of headings with respect to structure, degree of specialization, synonyms and homonyms. The study is descriptive in nature, gives a status report on the variety of headings used in clinical practice, provides necessary material for a normative approach focusing on a truly multi-professional patient record in the future.

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TECHNOLOGY

TEKNIKVETENSKAP

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