Documentation of work ability data in occupational health records

In Finland, patient health records are structured in the same way. Patient data entries are grouped using national headings and each data entry must have at least one heading.

To determine the use of national headings for the documentation of work ability data and to gather the experience of professionals on usefulness, ease of use and usability of national headings in occupational health services (OHSs).

An electronic questionnaire and a semi-structured themed interview were used to collect data. Data were analysed using SPSS Statistics 24 and interview material was analysed by deductive content analysis using ATLAS.ti.

A total of 359 people completed the questionnaire. Most of the work ability data were documented using the headings history, plan and current status. More than half of respondents felt that using national headings improved quality and allowed greater control. Almost all respondents thought that learning to use national headings was easy. During the interviews (n = 19), all respondents felt that use of national headings improved the quality of documentation. However, more than half stated that national headings were not well suited to documentation of work ability data.

These results can be used to develop national documentation standards, as well as electronic health records, to support healthcare professionals' interactions with working-age patients. Earlier studies of national headings in OHSs were not found.