Patients' Needs Assessment Documentation in Multidisciplinary Electronic Health Records

The purpose of this study is to describe and discuss physicians' and nurses' documentation of the patient's needs assessment in electronic health records (EHR) in the neurological care setting. Both physicians and nurses collect, record and interpret data during patient care episodes. Assessment of patient's need for care and treatment is an important part of the care process. Planning, implementation and outcome assessment of the care process are based on needs assessment data. The data of this study consist of 48 neurological medical narratives and nursing care plans. The data were analyzed using descriptive statistics and content analysis. Physician's medical narratives include referrals to physiotherapy and consultations in other care specialities in which they have recorded the reason for the care, anamnesis and status praesens data. Nurses have documented patient's needs assessment in nursing care plans using Finnish Classification of Nursing Diagnoses (FiCND) and additional narrative text. Physicians' and nurses' patient needs assessment documentation complement each other. Nursing documentation includes more detailed information about patients' needs for care due the use of FiCND in documentation. The use of standardised documentation improves quality of the documentation and retrieval of data from EHR.