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. 2019 Dec;26(1):e100106.
doi: 10.1136/bmjhci-2019-100106.

Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers

Anoop Dinesh Shah  1   2 , Nicola J Quinn  2 , Afzal Chaudhry  3   4 , Ralph Sullivan  5   6 , Julian Costello  6   7 , Dermot O'Riordan  8 , Jan Hoogewerf  2   9 , Martin Orton  4 , Lorraine Foley  4 , Helene Feger  4 , John G Williams  2   10
Affiliations

Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers

Anoop Dinesh Shah et al. BMJ Health Care Inform. 2019 Dec.

Abstract

Background: Accurate recording of problems and diagnoses in health records is key to safe and effective patient care, yet it is often done poorly. Electronic health record systems vary in their functionality and ease of use, and are not optimally designed for easy recording and sharing of clinical information. There is a lack of professional consensus and guidance on how problems and diagnoses should be recorded.

Methods: The Professional Record Standards Body commissioned work led by the Royal College of Physicians Health Informatics Unit to carry out a literature review, draft guidance, carry out an online consultation and round table discussion, and produce a report including recommendations for systems. A patient workshop was held to explore patient preferences for mechanisms for sharing diagnosis information between primary and secondary care.

Results: Consensus was reached among medical specialties on key elements of diagnosis recording, and draft guidance was produced ready for piloting in a variety of care settings. Patients were keen for better ways for diagnosis information to be shared.

Discussion: Improving the recording of diagnoses and problems will require a major effort of which the new guidance is only a part. The guidance needs to be embedded in training, and clinical systems need to have improved, standardised functionality. Front-line clinicians, specialist societies, clinical informaticians and patients need to be engaged in developing information models for diagnoses to support care and research, accessible via user-friendly interfaces.

Keywords: information management; information systems; medical informatics; record systems.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Survey respondents’ satisfaction with aspects of the draft guidance on diagnosis recording.
Figure 2
Figure 2
A potential model for shared problem and diagnosis records. GP, general practice; HFpEF, heart failure with preserved ejection fraction.
See this image and copyright information in PMC

References

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