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Documentation of the Clinical Phase of the Cardiac Rehabilitation Process in a Finnish University Hospital District

Lotta Kauhanen, Laura-Maria Murtola, Juho Heimonen, Tuija Leskinen, Kari Kalliokoski, Elina Raivo, Tapio Salakoski, Sanna Salanterä, Documentation of the Clinical Phase of the Cardiac Rehabilitation Process in a Finnish University Hospital District. In: Kaija Saranto, Maaret Castrén, Tiina Kuusela, Sami Hyrynsalmi, Stina Ojala (Eds.), Safe and Secure Cities, Communications in Computer and Information Science 450, 57–67, Springer International Publishing, 2014.

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.

BibTeX entry:

@INPROCEEDINGS{inpKaMuHeLeKaRaSaSa14a,
  title = {Documentation of the Clinical Phase of the Cardiac Rehabilitation Process in a Finnish University Hospital District},
  booktitle = {Safe and Secure Cities},
  author = {Kauhanen, Lotta and Murtola, Laura-Maria and Heimonen, Juho and Leskinen, Tuija and Kalliokoski, Kari and Raivo, Elina and Salakoski, Tapio and Salanterä, Sanna},
  volume = {450},
  series = {Communications in Computer and Information Science},
  editor = {Saranto, Kaija and Castrén, Maaret and Kuusela, Tiina and Hyrynsalmi, Sami and Ojala, Stina},
  publisher = {Springer International Publishing},
  pages = {57–67},
  year = {2014},
  keywords = {documentation; physical therapy; cardiac rehabilitation; electronic health records; patient safety; registry-based research},
  ISSN = {1865-0929},
}

Belongs to TUCS Research Unit(s): Turku BioNLP Group

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