Documentation of Patient Problems and Strengths in Electronic Health Records
Grace Gao*, Madeleine Kerr, Ruth Lindquist and Karen Monsen
School of Nursing, University of Minnesota, Minneapolis, MN, USA
- *Corresponding Author:
- Grace Gao
School of Nursing, University of Minnesota
Minneapolis, MN 55455, USA
Received date: June 2, 2016; Accepted date: June 16, 2015; Published date: June 23, 2015
Citation: Gao G, Kerr M, Lindquist R, Monsen K (2016) Documentation of Patient Problems and Strengths in Electronic Health Records. Intern Med 6: 221. doi:10.4172/2165-8048.1000221
Copyright: © 2016 Gao G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Background: A whole-person representation captures not only patient problems but also patient strengths. To better understand and inform practice of person-centered care and documentation using a whole-person representation, a critical review of literature was conducted of the current state of patient problems and strengths documentation in electronic health records.
Methods: The informatics model of Data, Information, Knowledge and Wisdom is employed to develop this critical review. Two scientific databases were used to conduct a systematic search: CINAHL and Ovid Medline with the following search terms: strength*, problem*, whole person, wellbeing or well-being, electronic health record*, personal health record*, EHR*, and PHR*. 602 articles were returned. All articles were screened through review of titles, abstracts, or full texts. 24 articles were selected for this review.
Results: Four themes have emerged from this critical review. They are individual or cross-institutional use of problem-oriented EHRs, extension of problem-based EHRs with other integration, patient-centered integration of the problem-oriented EHR build, and construction of a whole-person representation to include strengths in the EHR documentation. The vast majority of articles focus on problem-based diagnoses and practices. Early reports of strengths documentation were found using a standardized interface terminology and ontology, the Omaha System. Results of two studies demonstrated the feasibility of using the Omaha System for whole-person documentation to capture perception of both problems and strengths.
Conclusion: Clinical information in EHRs is typically structured by problem-based diagnoses; however, there is emerging documentation of formalized strengths attributes using the Omaha System, which may promote a holistic approach to clinical practice and documentation using a person-centered, strength-based ontology.