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Documentation in Child and School Health services: Mapping health information from a biopsychosocial perspective using the ICF-CY
Jönköping University, School of Health Science, HHJ, Dep. of Nursing Science. Jönköping University, School of Health Science, HHJ. CHILD.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to analyze whether the documentation in the Child Health Services (CHS) and School Health Services (SHS) reflects a holistic view on health as represented by a bio-psychosocial perspective.

The method used based on four studies, all with a descriptive design. Analyzed documents contained lists of health terms recommended to be included in the health record (HR) (I), requested information in health questionnaires (II) and the content of free text notes in health records (HRs) (III). A deductive approach was used on an item-by-item basis (I, II), and for the free text notes in HRs a qualitative content analysis with an inductive approach was chosen (III). Nurses’ and physicians’ views on documentation and electronic HR were analyzed with the help of a quantitative questionnaire design (IV).

Results showed that information on developed lists of health terms recommended to be included in an electronic version of the HR (I) could be linked to codes in the ICF-CY. The linked health terms were mainly focused on the body, i.e. a biological perspective on health. Several health terms linked to two or more codes, which indicate a need for more clarity in content descriptions. In the locally produced health questionnaires (Study II), for all age groups, a majority of the linked health items counted only once, and involved a psychosocial perspective on health. These health items were related to communication, psychosomatic symptoms and taking care of one’s health (II). The results in the free text notes in HRs (III) mainly focused on a psychosocial perspective on health and were represented across all age groups, but were unevenly distributed. There was new health information in the free text notes which had not been covered in the standardized  part  of  the  HRs. The respective staffs acknowledged that more health information than was documented in the HR was transferred between the CHS and SHS (IV). This information concerned foremost family function. The CHS and SHS had positive opinions regarding the possibilities of an electronic version of the HR.

Conclusions: The predominant medical content of lists of health terms was supplemented with health information related to psychosocial health in health questionnaires and in the free text notes in the HR. However, the focus was on the child as a person rather than a child within a family and preschool/school environment, and was strongly related to age groups. More information on children’s health than was recorded was transferred between and within the services. The utility of the ICF-CY as a tool has been confirmed, and indicates challenges to develop a common language to document more on psychosocial health.

Place, publisher, year, edition, pages
School of Health Sciences Jönköping University , 2012. , p. 77
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 29
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-17948ISBN: 978-91-85835-28-7 (print)OAI: oai:DiVA.org:hj-17948DiVA, id: diva2:516263
Public defence
2012-04-27, Forum Humanum, Hälsohögskolan, 551 11, Jönköping, 13:00
Opponent
Supervisors
Available from: 2012-04-17 Created: 2012-04-17 Last updated: 2012-09-12Bibliographically approved
List of papers
1. Mapping of children's health and development data on population level using the classification system ICF-CY
Open this publication in new window or tab >>Mapping of children's health and development data on population level using the classification system ICF-CY
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, p. 51-57Article in journal (Refereed) Published
Abstract [en]

AIM: The aim of this study was to investigate if essential health and development data of all children in Sweden in the Child Health Service (CHS) and School Health Service (SHS) can be linked to the classification system International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY). Method: Lists of essential health terms, compiled by professionals from CHS and SHS, expected to be used in the national standardised records form the basis for the analysis in this study. The essential health terms have been linked to the codes of ICF-CY by using linking rules and a verification procedure. RESULTS: After exclusion of terms not directly describing children's health, a majority of the health terms could be linked into the ICF-CY with a high proportion of terms in body functions and a lower proportion in activity/participation and environment respectively. Some health terms had broad description and were linked to several ICF-CY codes. The precision of the health terms was at a medium level of detail. CONCLUSION: ICF-CY can be useful as a tool for documenting child health. It provides not only a code useful for statistical purposes but also a language useful for the CHS and SHS in their work on individual as well as population levels. It was noted that the health terms used by services mainly focused on health related to body function. This indicates that more focus is needed on health data related to child's functioning in everyday life situations.

Keyword
Child, child health services, classification, documentation, ICF-CY, health records, public health informatics, pupil, school health services, Sweden
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-13880 (URN)10.1177/1403494810378918 (DOI)000286610700008 ()20688792 (PubMedID)
Available from: 2010-12-07 Created: 2010-12-07 Last updated: 2017-12-11Bibliographically approved
2. Contents of Swedish school health questionnaires
Open this publication in new window or tab >>Contents of Swedish school health questionnaires
2011 (English)In: British Journal of School Nursing, ISSN 1752-2803, Vol. 6, no 2, p. 82-88Article in journal (Refereed) Published
Abstract [en]

Aim: This study aims to analyse and link the content of the health information requested in questionnaires used locally in Swedish child and school health services. Background: In industrialized countries, children's health needs are changing from physical to psychosocial needs and the questionnaires used for health screening and guiding health promotion must therefore adapt to these changes. Methods: Questionnaires were analysed, together with health items linked to the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY). The inter-rater agreement for linking was 80%. Standard age groups were used to improve the comparability across different questionnaires. Results: The information requested for the youngest children focused on communication and acquiring language. For the children aged 6 years and above, health questionnaires related to mental functions, the school situation, psychosomatic symptoms and issues associated with taking care of one's health. Conclusions: The information relating to health in questionnaires revealed that interest focused on health items strongly related to the different age groups and to psychosocial health. The focus was the child as a person rather than the child within a family and school environment.

Keyword
Children, Questionnaires, Psychosocial health, School health services, ICF-CY, Sweden
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-15995 (URN)
Available from: 2011-09-07 Created: 2011-09-07 Last updated: 2016-03-04Bibliographically approved
3. Psychosocial health information in free text notes of Swedish children's health records
Open this publication in new window or tab >>Psychosocial health information in free text notes of Swedish children's health records
Show others...
2013 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 27, no 3, p. 616-623Article in journal (Refereed) Published
Abstract [en]

Background: High-quality documentation of children’s health is an important priority in health care given trends of declining mental health and reduced well-being in children. There is a lack of information concerning psychosocial health in the standardized part of the national health record in the Child Health Service and the School Health Service in Sweden. Further, little is known if the free text notes in the health record, besides information on physical health, also include information on children’s psychosocial health. The aim of this study was to describe what is recorded concerning children’s health and development in free text notes.

Methods: The study was based on a retrospective analysis of text using an inductive approach for qualitative analyses of content.

Results: The analysis of the free text notes in the health records yielded seven categories: development, family, health problems, living habits, medical issues, preschool/school and leisure, and well-being. The categories mainly covered psychosocial aspects of health and were not only about health and development problems of the child but also what was covered during the visits. The information was unevenly distributed across the ages. A stronger focus on the youngest age groups within a family and preschool setting is needed. There was novel information in the free text notes such as pain, general health, emotions, mother’s mental health and leisure activities, which was not covered in the standardized part of the health records.

Conclusion: The free text notes mainly reflected a psychosocial perspective on health. The findings of this study suggest that requesting more information on children’s psychosocial health in the standardized part of the health records could contribute to more comprehensive and informative health records in the Child health Service and the School Health Service in Sweden.

Keyword
health, Child Health Service, School Health Service, health records, psychosocial health, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:hj:diva-19374 (URN)10.1111/j.1471-6712.2012.01059.x (DOI)000321625800015 ()HHJCHILDIS, HHJKvalitetIS (Local ID)HHJCHILDIS, HHJKvalitetIS (Archive number)HHJCHILDIS, HHJKvalitetIS (OAI)
Available from: 2012-09-08 Created: 2012-09-08 Last updated: 2017-12-07Bibliographically approved
4. Views on health information and perceptions of standardized electronic records among staff in Child and School Health Services
Open this publication in new window or tab >>Views on health information and perceptions of standardized electronic records among staff in Child and School Health Services
2011 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 19, no 2, p. 201-208Article in journal (Refereed) Published
Abstract [en]

AIM: To investigate how nurses and physicians in the Child and School Health Services view the documentation and transfer of health information. Another aim concerns their perceptions of a nationally standardized electronic health record.

BACKGROUND: Problems of mental health among children and adolescents currently pose one of the greatest challenges facing all European countries. The continuity of health work demands that all health information follow the child's development, disregarding the organizational arrangement.

METHODS: The study was descriptive and comprised 484 questionnaires to nurses and physicians in the Child and School Health Services in Sweden.

RESULTS: More information about children's health was transferred than documented in the health record when children started school. This additional health information concerned psychosocial health and foremost family function. There was a consensus concerning the usefulness of a nationally standardized electronic health record, although there were group differences between nurses and physicians.

CONCLUSIONS: All information about children's health is not documented although the professional's positive perceptions to electronic health records may provide a basis to improve documentation.

IMPLICATIONS FOR NURSING MANAGEMENT: The results indicate challenges to develop a common language to document psychosocial issues necessary for providing a holistic view of children's health.

Keyword
Adolescent, Adult, Attitude of Health Personnel, Chi-Square Distribution, Child, Child Health Services/organization & administration, Communication, Documentation, Female, Health Care Surveys, Holistic Nursing, Humans, Male, Medical Records Systems, Computerized/organization & administration, Middle Aged, Nurses/psychology, Nursing Evaluation Research, Perception, Physicians/psychology, Program Development, Questionnaires, School Health Services/organization & administration, Sweden, Young Adult
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-17188 (URN)10.1111/j.1365-2834.2010.01201.x (DOI)000288080500006 ()21375623 (PubMedID)1365-2834 (Electronic) 0966-0429 (Linking) (ISBN)
Available from: 2012-01-16 Created: 2012-01-16 Last updated: 2017-12-08Bibliographically approved

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