METHODS: Qualitative interviews (N = 20) were conducted among medical secretaries, medical doctors, nurses, and registration advisers from psychiatric and somatic emergency departments in all regions of Denmark between September 2022 and March 2023. Content analysis was performed using NVivo.
RESULTS: Despite great efforts to standardize and assure the quality of registration in Denmark, almost all the healthcare professionals perceived registration practice as inconsistent and unreliable. Codes are often misclassified or unused due to insufficient time, non-standardized training, or insufficient information. The interview informants suggested that coding guidelines should be simplified and made more visible, alongside technical solutions in the electronic health record system.
CONCLUSIONS: The study findings resulted in eight overall recommendations for clinical practice that aim at improving the registration of patients presenting with self-harm or suicide attempts. This would be expected to help improve surveillance and prevention programs.
方法:对医疗秘书进行了定性访谈(N=20),医生,护士,2022年9月至2023年3月期间,来自丹麦所有地区的精神科和躯体急诊科的注册顾问。使用NVivo进行含量分析。
结果:尽管丹麦为标准化和确保注册质量做出了巨大努力,几乎所有的医疗保健专业人员都认为注册实践不一致和不可靠。由于时间不足,代码经常被错误分类或未使用,非规范化培训,或信息不足。采访线人建议,编码指南应该简化,更加明显,以及电子健康记录系统中的技术解决方案。
结论:研究结果为临床实践提供了八项总体建议,旨在改善自我伤害或自杀未遂患者的注册。预计这将有助于改善监测和预防计划。