[Collaborated admission to a surgical department]

Abstract

Background: The medical case record is an important tool for securing high quality in treatment and care of patients. Efficient and accurate documentation of diagnostic and therapeutic procedures, patient information etc. is crucial.

Material and methods: We have prospectively studied how time and patient satisfaction are influenced when nurse and doctor together ("combined model") take the patient's medical history, perform a clinical examination, and inform the patient, compared to separate history-taking by nurse and doctor ("separate model").

Results: The mean nurse time per patient increased from 17 min in the separate model to 21 min in the combined model (p = 0.01). Corresponding time use by the doctor was 26 min and 21 min (p = 0.04), and for the patient 43 min and 23 min (p < 0.001). Patients reported the two models to be comparable in quality.

Interpretation: The "combined registration model" secures high quality of the medical case record, respects the patient's time, and signals professional collaboration to the patient.