Clinical content (SFI) shall ensure that electronic healthcare
records (EHR) support clinical processes and the documentation of
these, where clinical guidelines are evidence based recommendations
for the clinical processes. It is known that there is a difference
between the evidence suggested treatment and the treatment that
the patient receives. This implies that the health sector might provide
treatment that is not of the highest quality, with the patient at
risk of receiving inadequate and inappropriate treatment. Therefore,
this project focuses on how the work with SFI in EHR and ITsystems
can facilitate the application of clinical guidelines.
First the potentials in incorporating clinical guidelines into SFI are
analysed by answering; why are clinical guidelines not applied in
clinical practice as wells as and what are the possibilities to incorporate
clinical guidelines into SFI to ensure the application of the
guidelines in practice. Then IT-based SFI documentation templates
are modelled to facilitate the implementation of clinical guidelines
in clinical practice. Knowledge gathering for the analysis is constituted
of literature reviews and an interview. The modelling of documentation
templates are achieved through a systematic review of
clinical guidelines and the description for continuity of care (kræftpakkeforløb)
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Extensive barriers prevent the application of clinical guidelines
in clinical practice and range from the development of guidelines
to the clinician’s individual attitude and behaviour. Therefore,
the documentation templates modelled in this project are characterised
by adopting clinical guidelines in clinical practice through
the documentation process and thereby facilitate the application of
clinical guidelines in clinical practice.
SFI documentation templates based on clinical guidelines has
the potential to facilitate the application of clinical guidelines by
adopting these in clinical practice and thereby making it possible
to evaluate whether what is documented is in concordance with
the clinical guidelines. The documentation templates modelled in
this project conceptualise this, but an actual development must be
carried out in collaboration with the clinicians who are to use the
templates.