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

Abstract

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 multiprofessional patient record in the future.