Towards a multi-professional patient record--a study of the use of headings

This paper reports on the differences and similarities of used headings among Swedish health care professionals; nurses, occupational therapists, physiotherapists, dietetics, logopedics, welfare officers and general practitioners. The background of the study is a national project where representatives of the different health care professionals compiled used headings from clinical practice. Based on that survey, a hierarchical system of headings was constructed in accordance with the notion of record items and record item complexes described in the European Health Care Record Architecture (EHCRA). The work was done separately by the different health care professionals, leading to separate lists of headings. The current study reports on an analysis of these multi-professional lists of headings with respect to structure, degree of specialization, synonyms and homonyms. The study is descriptive in nature, giving a status report of the variety of used headings in clinical practice, providing necessary material for a normative approach with focus on a truly multi-professional patient record in the future.