Interprofessional Documentation: Where is Everyone?

Area of Science:

• Healthcare Informatics
• Health Services Research
• Interprofessional Education and Practice

Background:

• Electronic Health Records (EHRs) are increasingly integral to healthcare delivery and interprofessional collaboration.
• A significant gap exists in understanding interprofessional documentation (IPD) practices, particularly for healthcare professions outside of medicine and nursing.
• The definition and scope of IPD require further clarification within the context of modern healthcare systems.

Approach:

• Conducted a rapid review of existing literature to identify studies on interprofessional documentation within EHR systems.
• Analyzed the current state of research concerning documentation practices among diverse healthcare professional teams.
• Synthesized findings to propose a working definition of IPD.

Key Points:

• Interprofessional documentation (IPD) is defined as the collaborative process where two or more healthcare providers document patient information within an electronic system to coordinate care.
• Research on IPD is notably scarce for professions beyond physicians and nurses, indicating an underexplored area in health informatics.
• The current literature does not adequately address the nuances and benefits of IPD across the multidisciplinary care spectrum.

Conclusions:

• The review underscores a critical need for expanded research into interprofessional documentation (IPD) to optimize care coordination and EHR utilization.
• Future studies should focus on developing and evaluating IPD strategies across various healthcare professions to enhance team-based care.
• Establishing a clearer understanding and standardized approach to IPD is essential for leveraging EHR capabilities fully in interprofessional practice.