A Retrospective Analysis of Health, Health Care, and Legal Requirements as Reflected in Predefined Headings in an EHR

Abstract

Objectives: To study health, health care, and legal requirements as reflected in predefined headings that were applied by users in a Swedish multi-professional electronic health record (EHR).

Method: Predefined headings (n = 3 596) applied to 20 398 104 occasions by health care professionals in a module for care documentation in an EHR were analysed. A conventional qualitative content analysis was used to explore health and health care as reflected in the predefined headings. Furthermore, a comparison was made between the health and health care aspects and the Swedish Patient Data Act (PDA) to examine whether the aspects corresponded to legal requirements.

Results: The analysis yielded a meaningful structure that included five categories and 23 subcategories. The categories were Description of the patient, Health care process, Resources employed, Administrative documentation, and Development and research. Of the 23 subcategories, 15 corresponded to four of the seven legal requirements in the PDA. No corresponding subcategories were observed for three of the legal requirements.

Conclusions: The predefined headings of the multi-professional EHR were possible to analyse and categorise. The analysis showed that the headings reflected a wide range of health and health care and that synonyms or similar terms occurred as headings. The majority of the subcategories corresponded to the legal requirements of the PDA. The legal requirements that referred to patient rights did not have any corresponding subcategory. Subcategories that were found and that concerned goals to be attained and intervention outcomes were not explicitly expressed as legal requirements in the PDA.