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. 2008 May 12;170(20):1747-52.

[Basic registration of risk factors in medical records. Malnutrition, overweight, physical inactivity, smoking and alcohol]

[Article in Danish]
Hanne Tønnesen  1 , Nina Roswall, Mette Dissing Odgaard, Klaus Michael Pedersen, Karen Lindorff Larsen, Bjørn Mathiassen, Richard Farlie, Anders Elbirk, Mogens Hüttel, Lasse Danborg, Vibeke Vestermark, Anette Lykke Petri, Niels Ebbehøj, Marianne Frederiksen, Tatjana Hejgaard
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  • PMID: 18489891

[Basic registration of risk factors in medical records. Malnutrition, overweight, physical inactivity, smoking and alcohol]

[Article in Danish]
Hanne Tønnesen et al. Ugeskr Laeger. .

Abstract

Introduction: Lifestyle factors are important for clinical outcome. Systematic and early identification of these factors is important in order to offer relevant lifestyle intervention programmes. The objective was to evaluate whether basic registration of risk factors was understandable, applicable and sufficient in the clinical workday.

Materials and methods: Eleven clinical specialists participated from a broad range of departments. They performed identification and registration of malnutrition, overweight, physical inactivity, smoking and harmful alcohol consumption based on medical records from own departments (in total 2420 times). The specialists then evaluated the understanding, applicability and sufficiency (363 times). Their comments were noted.

Results: Identification and registration was accomplished for 85% (0-100%) of the records. Except for two fields--"measurements of waist" and "other training programs"--the specialists found the basic registration understandable, applicable and sufficient. They lacked more details regarding stress-response in the information material and pointed out inconsistencies in the wording. Ten specialists found that the recommended clinical approach was possible to implement in the present routines.

Conclusion: Basic registration of lifestyle factors for adult patients is possible and clinical relevant. It is recommended that the Danish National Board of Health uses the results in future.

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