Abstract
Cardiac rehabilitation (CR) is an essential part of the treatment and recovery process of cardiac patients by which mortality can be reduced. CR is documented in the patient’s health records to ensure continuity of care. The aim of this study was to describe and evaluate the contents of the clinical phase documentation of CR according to the care notes of physical therapists and physiatrists. The data set used in this register-based study consisted of the electronic health records (EHR) of patients, with any type of cardiac problem admitted to a Finnish university hospital district between 2005 and 2009. The main findings indicate that 1) only a small part of the eligible patients’ records include CR documentation 2) the patients with CR documentation are relatively old when compared to the age distribution of all cardiac patients (p<0,001), 3) the documentation does not systematically follow the national guidelines, 4) the evaluation of treatment is rarely documented, and 5) the most commonly documented therapy concerned walking- and breathing exercises.
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References
World Health Organization. Global status report on noncommunicable disaeses 2010. Geneva, World Health Organization (2011a), http://www.who.int/nmh/publications/ncd_report_full_en.pdf
Nichols, M., Townsend, N., Luengo-Fernandez, R., Leal, J., Gray, A., Scarborough, P., Rayner, M.: European Cardiovascular Disease Statistics 2012. European Heart Network, Brussels, European Society of Cardiology, Sophia Antipolis (2012)
Ambrosy, A.P., Fonarow, G.C., Butler, J., Chioncel, O., Greene, S.J., Vaduganathan, M., Nodari, S., Lam, C.S., Sato, N., Shah, A.N., Gheorghiade, M.: The Global Health and Economic Burden of Hospitalizations for Heart Failure: Lessons Learned From Hospitalized Heart Failure Registries. J. Am. Coll. Cardiol. 63(12), 1123–1133 (2014)
Heran, B.S., Chen, J.M., Ebrahim, S., Moxham, T., Oldridge, N., Rees, K., Thompson, D.R., Taylor, R.S.: Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst. Rev. 7, CD001800 (2011)
Taylor, R.S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., Skidmore, B., Stone, J.A., Thompson, D.R., Oldridge, N.: Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am. J. Med. 116(10), 682–692 (2004)
Finlex 17.8.1992/785. Laki potilaan asemasta ja oikeuksista, http://www.finlex.fi/fi/laki/ajantasa/1992/19920785
Finlex 298/2009. Sosiaali- ja terveysministeriön asetus potilasasiakirjoista, http://www.finlex.fi/fi/laki/alkup/2009/20090298
World Confederation for Physical Therapy: WCPT guideline for records management: record keeping, storage, retrieval and disposal, London, UK (2011), http://www.wcpt.org/guidelines/records-management
Fysioterapiapalvelujen sähköinen dokumentointi - ohje rakenteiseen kirjaamiseen potilastietojärjestelmässä. Versio 1.0 (2012), http://www.suomenfysioterapeutit.fi/index.php?option=com_content&view=article&id=293&Itemid=508
Kolber, M., Lucado, A.M.: Risk management strategies in physical therapy: documentation to avoid malpractice. Int. J. Health Care Qual. Assur. Inc. Leadersh. Health Serv. 18(2-3), 123–130 (2005)
Wang, N., Hailey, D., Yu, P.: Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J. Adv. Nurs. 67(9), 1858–1875 (2011)
Mäkinen, A., Penttilä, U.R.: Sepelvaltimopotilaiden kuntoutus julkisessa terveydenhuollossa. Selvitys kuntoutuksen määrästä, sisällöstä ja järjestämistavoista. Suomen Sydänliiton julkaisuja 1 (2007), http://www.sydanliitto.fi/c/document_library/get_file?uuid=03135813-392c-4251-ab8f-abde05c110e9&groupId=14302
European Association of Cardiovascular Prevention and Rehabilitation Committee for Science Guidelines; EACPR, Corrà, U., Piepoli, M.F., Carré, F., Heuschmann, P., Hoffmann, U., Verschuren, M., Halcox, J., Document Reviewers, Giannuzzi, P., Saner, H., Wood, D., Piepoli, M.F., Corrà, U., Benzer, W., Bjarnason-Wehrens, B., Dendale, P., Gaita, D., McGee, H., Mendes, M., Niebauer, J., Zwisler, A.D., Schmid, J.P.: Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur. Heart J. 16, 1967–1974 (2010)
Achttien, R.J., Staal, J.B., van der Voort, S., Kemps, H.M., Koers, H., Jongert, M.W., Hendriks, E.J.: Exercise-based cardiac rehabilitation in patients with coronary heart disease: a practice guideline. Practice Recommendations Development Group. Neth. Heart J. 10, 429–438 (2013)
Hulzebos, E.H., Smit, Y., Helders, P.P., van Meeteren, N.L.: Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst. Rev. 11, CD010118 (2012)
Savage, P.D., Sanderson, B.K., Brown, T.M., Berra, K., Ades, P.A.: Clinical research in cardiac rehabilitation and secondary prevention: looking back and moving forward. Journal of Cardiopulmonary Rehabilitation and Prevention 31(6), 333–341 (2011)
Cortes, O., Arthur, H.M.: Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review. American Heart Journal 151(2), 249–256 (2006)
Arena, R., Williams, M., Forman, D.E., Cahalin, L.P., Coke, L., Myers, J., Hamm, L., Kris-Etherton, P., Humphrey, R., Bittner, V., Lavie, C.J.: Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association. Circulation 125(10), 1321–1329 (2012), American Heart Association Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity and Metabolism
Ghisi, G.L., Polyzotis, P., Oh, P., Pakosh, M., Grace, S.L.: Physician factors affecting cardiac rehabilitation referral and patient enrollment: a systematic review. Clinical Cardiology 36(6), 323–335 (2013)
Mansah, M., Griffiths, R., Fernandez, R., Chang, E., Thuy Tran, D.: Older Folks in Hospitals: The Contributing Factors and Recommendations for Incident Prevention. J. Patient Saf. (2014) [Epub ahead of print]
Wahr, J.A., Prager, R.L., Abernathy III, J.H., Martinez, E.A., Salas, E., Seifert, P.C., Groom, R.C., Spiess, B.D., Searles, B.E., Sundt III, T.M., Sanchez, J.A., Shappell, S.A., Culig, M.H., Lazzara, E.H., Fitzgerald, D.C., Thourani, V.H., Eghtesady, P., Ikonomidis, J.S., England, M.R., Sellke, F.W., Nussmeier, N.A.: Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation 128(10), 1139–1169 (2013), American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research
Penoyer, D.A., Cortelyou-Ward, K.H., Noblin, A.M., Bullard, T., Talbert, S., Wilson, J., Schafhauser, B., Briscoe, J.G.: Use of electronic health record documentation by healthcare workers in an acute care hospital system. J. Healthc. Manag. 59(2), 130–144 (2014)
Häyrinen, K., Saranto, K., Nykänen, P.: Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int. J. Med. Inform. 77(5), 291–304 (2008)
Edwards, S.T., Neri, P.M., Volk, L.A., Schiff, G.D., Bates, D.W.: Association of note quality and quality of care: a cross-sectional study. BMJ Qual. Saf. 23(5), 406–413 (2013)
Schiff, G.D., Bates, D.W.: Can electronic clinical documentation help prevent diagnostic errors? N. Engl. J. Med. 362(12), 1066–1069 (2010)
Roth, C.P., Lim, Y.-W., Pevnick, J.M., et al.: The challenge of measuring quality of care from the electronic health record. Am. J. Med. Qual. 24, 385–394 (2009)
Bergh, A.L., Bergh, C.H., Friberg, F.: How do nurses record pedagogical activities? Nurses’ documentation in patient records in a cardiac rehabilitation unit for patients who have undergone coronary artery bypass surgery. J. Clin. Nurs. 16(10), 1898–1907 (2007)
Gustavsen, M., Mengshoel, A.M.: Clinical physiotherapy documentation in stroke rehabilitation: an ICIDH-2 beta-2 based analysis. Disabil. Rehabil. 25(19), 1089–1096 (2003)
World Health Organization: International Statistical Classification of Diseases and Related Health Problems. 10th Revision, vol. 2. Instructional manual. 2010 Edition (2011b), http://apps.who.int/classifications/icd10/browse/2010/en
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Kauhanen, L. et al. (2014). Documentation of the Clinical Phase of the Cardiac Rehabilitation Process in a Finnish University Hospital District. In: Saranto, K., Castrén, M., Kuusela, T., Hyrynsalmi, S., Ojala, S. (eds) Safe and Secure Cities. WIS 2014. Communications in Computer and Information Science, vol 450. Springer, Cham. https://doi.org/10.1007/978-3-319-10211-5_6
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DOI: https://doi.org/10.1007/978-3-319-10211-5_6
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