<p>Sjuksköterskan är dokumentationsskyldig enligt ett flertal lagar och förordningar. Dessa ger oss ramar men inga enhetliga riktlinjer och verktyg för hur strukturen för omvårdnadsdokumentationen ska se ut. Syftet med litteraturstudien var att granska hur den vetenskapliga litteraturen beskriver omvårdnadsdokumentationen utifrån VIPS-modellen och ICF som tillämpbar inom omvårdnadsdomänen. Metoden som användes var litteraturstudie där sammanlagt 18 st. vetenskapliga artiklar granskades. Resultatet påvisar brister i omvårdnadsdokumentationen. Få av de granskade journalerna uppfyllde kraven enligt patientjournallagen. Enligt granskningsinstrumentet Cat-ch-Ing förbättrades dokumentationen efter utbildningsinterventioner som byggde på VIPS-modellen. </p><p>Det framkom en diskrepans mellan patienters egen uppfattning av sina problem, sjuksköterskors uppfattning och vad som fanns dokumenterat i journalen. Sjuksköterskan skriver ner sina iakttagelser utan att stämma av med patienten. Studierna visade att de flesta omvårdnadsdiagnoser kunde omvandlas till International Classification of Functioning, Disability and Health (ICF) koder. I vissa fall ansåg sjuksköterskorna att koderna inte var tillräckligt specifika. Konklusionen är att en dokumentationsmodell eller klassifikation inte är tillräckligt för att säkerställa kvalitén i omvårdnadsdokumentationen utifrån omvårdnadsprocessen och gällande lagar. Som komplement krävs kontinuerlig journalgranskning och återkommande utbildningsinterventioner. ICF-klassifikationen anses tillämpbar inom omvårdnadsdomänen och kan främja en tvärprofessionell kommunikation. De tillkortakommanden som identifierats kan undanröjas genom att sjuksköterskor tar en aktiv roll i kommande revisioner. Om ICF skall implementeras måste det ske nationellt.</p><p>Dokumentationen bör förenklas i så stor grad som möjligt i standardiserade modeller så tid kan ägnas åt det patientnära arbetet. ICF är en strukturerad modell som kan underlätta dokumentationsarbetet.</p>

Sjuksköterskan är dokumentationsskyldig enligt ett flertal lagar och förordningar. Dessa ger oss ramar men inga enhetliga riktlinjer och verktyg för hur strukturen för omvårdnadsdokumentationen ska se ut. Syftet med litteraturstudien var att granska hur den vetenskapliga litteraturen beskriver omvårdnadsdokumentationen utifrån VIPS-modellen och ICF som tillämpbar inom omvårdnadsdomänen. Metoden som användes var litteraturstudie där sammanlagt 18 st. vetenskapliga artiklar granskades. Resultatet påvisar brister i omvårdnadsdokumentationen. Få av de granskade journalerna uppfyllde kraven enligt patientjournallagen. Enligt granskningsinstrumentet Cat-ch-Ing förbättrades dokumentationen efter utbildningsinterventioner som byggde på VIPS-modellen. Det framkom en diskrepans mellan patienters egen uppfattning av sina problem, sjuksköterskors uppfattning och vad som fanns dokumenterat i journalen. Sjuksköterskan skriver ner sina iakttagelser utan att stämma av med patienten. Studierna visade att de flesta omvårdnadsdiagnoser kunde omvandlas till International Classification of Functioning, Disability and Health (ICF) koder. I vissa fall ansåg sjuksköterskorna att koderna inte var tillräckligt specifika. Konklusionen är att en dokumentationsmodell eller klassifikation inte är tillräckligt för att säkerställa kvalitén i omvårdnadsdokumentationen utifrån omvårdnadsprocessen och gällande lagar. Som komplement krävs kontinuerlig journalgranskning och återkommande utbildningsinterventioner. ICF-klassifikationen anses tillämpbar inom omvårdnadsdomänen och kan främja en tvärprofessionell kommunikation. De tillkortakommanden som identifierats kan undanröjas genom att sjuksköterskor tar en aktiv roll i kommande revisioner. Om ICF skall implementeras måste det ske nationellt. Dokumentationen bör förenklas i så stor grad som möjligt i standardiserade modeller så tid kan ägnas åt det patientnära arbetet. ICF är en strukturerad modell som kan underlätta dokumentationsarbetet.

Magister Public Health - MPH / Background: The Provincial Government Western Cape (PGWC) Department of Health identified a lack of data on inpatient diagnoses and procedures in a form suitable to use for operational, strategic as well as financial health care planning. The only format in which diagnostic and procedure data was available was a paper based one encompassing individual patient notes in folders and discharge summaries. Making the data available in a coded format within an electronic database would facilitate storage, analysis and utilisation of that data for health service planning. Recognising the lack of availability of such coded data, this study was undertaken to evaluate different coding systems for their ability to code data in order to assist in deciding which coding systems best fit the need to facilitate easy and accurate recording of data on diagnoses and procedures from patient records. The identification of the most appropriate coding system for the context in which the PGWC Department of health functions should facilitate the easy recording, storage and retrieval of data that is accurate, reliable and useful for management decision making and would support optimal patient care. Aim: The aim of the study was to evaluate a selection of potentially suitable coding systems in order to determine which would be best able to code public sector district and regional hospital diagnostic and procedure data in the Western Cape Province. Method: A cross sectional analytical study design was used. Discharge diagnosis and procedure data were extracted from 342 patient folders from 3 district and 3 regional public hospitals in the Western Cape. This yielded 221 different diagnostic concepts and 126 different procedure concepts. The diagnostic concepts were further grouped into “all” diagnostic concepts recorded, diagnostic concepts recorded as “symptoms only” and diagnostic concepts recorded as “proper diagnoses”. The diagnostic coding systems evaluated were ICD-10 (International Classification of Diseases), ICPC-2 (International Classification of Primary Care 2nd edition) and ICD-10 Condensed Morbidity List. The procedure coding systems evaluated were CCSA-2001 (Current Procedure Terminology for South Africa) ICD-9-CM (International Classification of Diseases Clinical Modification 9th revision) and ICPC-2. The diagnoses and procedures were then coded in all of the coding systems being evaluated. Each diagnosis and procedure concept was matched with its representing concept in the coding system and scored according to the ability of the coding system to provide an “exact” match which was scored as (3) or a “partial” match scored as (2) or a “poor” match scored as (1) or “no” match scored as (0). Results: ICD-10 was better able to code diagnoses obtained from district and regional hospitals in the Western Cape compared to ICPC-2 and ICD-10 Condensed Morbidity list. For all recorded diagnostic concepts, ICD-10 was able to score 82% of the concepts as either an “exact” or a “partial” match compared to 79% in ICPC-2 and 30% in ICD-10-CL. ICD-10 consistently performed best across different stratification of diagnostic concepts namely concepts recorded as “proper diagnoses”, concepts recorded from regional hospitals only, concepts recorded from district hospitals only, concepts designated as “common diagnoses” and for concepts designated as “very common diagnoses”. In addition ICD-10 had zero diagnostic concepts for which “no match” could be found. CCSA -2001 proved to be the best coding system for coding procedures across all hospitals with an overall percentage of “exact” and “partial” matches of 83% compared to 65% for ICD-9-CM and 39% for ICPC-2 and also proved to be best across all strata. Conclusion: There were striking differences between the evaluated coding systems with regard to their ability to code diagnoses and procedures in the evaluated district and regional hospitals in the Western Cape Province. ICD-10 covers the scope of clinical diagnoses in more accurate and specific detail than ICPC-2 and ICD-10 CL. Though ICPC-2 is simpler and easier to use than ICD-10, it is not as detailed and specific as the latter but it proved ideal for symptoms rather than for specific diagnoses. ICD-10 Condensed Morbidity List was shown to be inadequate for coding diagnoses. However the difference between the two, although statistically significant were not very large and given the ease of use of ICPC-2, it could be recommended for use. As for procedures CCSA-2001 was assessed as being the most appropriate for coding procedures recorded in this setting compared to the other coding systems. ICPC-2 performed poorest for coding procedures across all evaluated settings and thus would be inappropriate to use. ICD-10 in most comparisons performed second best to ICPC-2 in terms of coding ability for diagnoses and could be considered for recommendation as a diagnostic coding tool.

The United States is one of the last countries to transition to the 10th edition of the International Classification of Diseases (ICD-10) coding system. The move from the 35-year-old system, ICD-9, to ICD-10, represents a milestone in the transformation of the 21st century healthcare industry. All covered healthcare entities were mandated to use the ICD-10 system on October 1, 2015, to justify medical necessity, an essential component in determining whether a service is payable or not. Despite the promising outcomes of this shift, more than 70% of healthcare organizations identified concerns related to education efforts, including lack of best practices for the ICD-10 transition. Lack of preparation for the implementation of ICD-10 undermines the clinical, technological, operational, and financial processes of healthcare organizations. This study was an exploration of implementation strategies used to overcome barriers to transition to ICD-10. A single case study was conducted, grounded by the conceptual framework of the technology acceptance model, to learn about ways to mitigate the barriers of this new coding system. Data were gathered from the review of documents, observations, and semistructured interviews with 9 participants of a public healthcare organization in Florida. Data were coded to identify themes. Key themes that emerged from the study included (a) in-depth ICD-10 training, (b) the prevalence of ICD-10 cheat sheets, (c) lack of system readiness, and (d) perception of usefulness of job performance. The results of the study may contribute to social change by identifying successful implementation strategies to mitigate operational disruptions that will allow providers to capture more detailed health information about the severity of patients' conditions.

Background: Physical activity questionnaires (PAQ) have been extensively used to determine physical activity (PA) levels. Most PAQ are derived from an energy expenditure-based perspective and assess activities with a certain intensity level. Activities with a moderate or vigorous intensity level are predominantly used to determine a person’s PA level in terms of quantity. Studies show that the time spent engaging in moderate and vigorous intensity PA does not appropriately reflect the actual PA behavior of older people because they perform more functional, everyday activities. Those functional activities are more likely to be considered low-intense and represent an important qualitative health-promoting activity. For the elderly, functional, light intensity activities are of special interest but are assessed differently in terms of quantity and quality. The aim was to analyze the content of PAQ for the elderly.

Sammenfatning Baggrund: Silversplints som behandling af hypermobilitet i fingrene hos personer med Ehlers-Danlos syndrom (EDS), er blevet mere udbredt i Danmark igennem de sidste 10 år, men der findes endnu ingen publicerede artikler om denne ortosebehandling og målgruppe. EDS er en gruppe sjældne heterogene bindevævssygdomme der kendetegnes ved generel hypermobilitet og smerte. Silversplints er håndlavede finger- og håndledsskinner af sølv, der er opbygget som et 3-punkts kraftsystem, der kan støtte og korrigere hypermobile led, modvirke fejlstillinger, samt begrænse bevægeligheden af fingrene. Formål: Bacheloropgaven har til formål at undersøge hvordan personer med EDS oplever at have silversplints på og hvilke vanskeligheder de oplever at have i hverdagen ud fra ICF. Metode: Bacheloropgaven anvender semi-structured interviews for at undersøge hvordan 3 deltagere med EDS oplever silversplints som behandling af hypermobilitet i fingrene. Den teoretiske referenceramme er Interpretative Phenomenological Analysis, som er en induktiv tilgang og iterativ proces. Resultat: Ud fra analysen opstod følgende 4 temaer: jeg er ikke min sygdom, energiforbrug, smertens mange ansigter, et farverigt liv. Gennem disse temaer gives et indblik i den positive effekt silversplints kan have for nogle personer med EDS. Anvendelsen af ICF viste at især funktionsevnen blev påvirket. Dette indebærer at kroppens funktioner og anatomi opleves vanskeligt, hvilket fører til begrænsninger i deltagernes mulighed for aktivitet og deltagelse. Konklusion: De identificerede temaer demonstrerer silversplints effekt på deltagernes mentale og fysiske helbred, samt giver et detaljeret billede af deltagernes oplevede problemer og funktionsevne, med og uden silversplints. Bacheloropgaven identificerer hvilke dele, kategorier og domæner indenfor ICF, personer med EDS oplever som problematiske, hvilket kan anvendes til at skabe et core set i videre forskning. / Abstract Background: Silversplints as orthotic management of finger hypermobility for people with Ehlers-Danlos Syndrome (EDS) has become more widespread in Denmark during the last 10 years, but no articles has yet been published about this orthotic management and population. EDS is a group of rare heterogeneous connective tissue disorders which is characterized by general hypermobility and pain. Silversplints are handmade finger and wrist splints made of silver, which are structured as 3-point force systems, which supports, corrects hypermobile joints, and corrects deformities as well as limits the movement of the fingers. Purpose: The aim of the thesis is to explore how people with EDS experience the use of silversplints and which difficulties they experience in their daily life based on ICF. Methods: The thesis uses semi-structured interviews to explore how 3 participants with EDS experience silversplints as orthotic management of hypermobility in the fingers. The theoretical framework is Interpretative Phenomenological Analysis, which is an inductive approach and iterative process. Results: From the analysis 4 themes emerged: I am not my disorder, energy consumption, the many faces of pain, a colorful life.  Through these themes an insight is gained into the positive effects silversplints may display for some people with EDS. The use of ICF showed that especially functioning and disability was affected. This involves that the body functions and structures are experienced as difficult, which leads to limitations in the participants possibility of activities and participation. Conclusion: The identified themes demonstrates silversplints’ effect on the participants mental and physical health, as well as provides a detailed picture of the participants’ experienced problems and functional capability, with and without silversplints. The thesis identifies which parts, categories, and domains within ICF, people with EDS experience as problematic, which can be used to generate a core set for further research.

A utilização adequada de um sistema de códigos é fundamental para a qualidade das informações de saúde registradas com o propósito de subsidiar o planejamento, a programação e a avaliação das ações de saúde. O objetivo do trabalho foi descrever o padrão de uso da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID) em atestados odontológicos apresentados em um serviço público federal com a finalidade de concessão de licença para tratamento de saúde. Analisou-se a concordância entre a codificação apresentada nos atestados e a codificação atribuída por cirurgiões-dentistas peritos oficiais; o grau de especificidade das codificações e a perspectiva de uso da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Este estudo concluiu que é necessário um aperfeiçoamento na utilização da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde Décima Revisão (CID-10) e que o uso complementar da Classificação Internacional de Doenças em Odontologia e Estomatologia (CID-OE) e da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) pode favorecer o processo de tomada de decisão quanto à necessidade de afastamento do trabalho, fornecendo dados relevantes para o monitoramento do absenteísmo por motivo odontológico. / Appropriate use of a code system is fundamental to the quality of registered health information in order to support the planning, programming and assessment of health measures. The objective of this study was to describe the pattern of use of the International Statistical Classification of Diseases and Related Health Problems (ICD) in dental certificates presented in a federal public service for the purpose of granting permission for medical treatment. The degree of agreement between the coding presented in health certificates and the coding given by official dental experts was assessed, as the degree of specificity of coding and the prospect of using the International Classification of Functioning, Disability and Health (ICF).This study concluded that an improvement is needed in the use of the International Statistical Classification of Diseases and Related Health Problems - Tenth Revision (ICD-10) and that complementary use of the International Classification of Diseases in Dentistry and Stomatology (ICD-DA) and International Classification of Functioning, Disability and Health (ICF) can aid the decision-making process regarding the need to take time off work, providing relevant data for monitoring absenteeism for dental reasons.

A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) é uma ferramenta para descrever os estados de saúde e estados relacionados à saúde. O objetivo do estudo foi utilizar a CIF para descrever o perfil de funcionalidade relacionado à incapacidade para o trabalho por motivo odontológico. Foram avaliados 41 indivíduos que necessitaram de afastamento do trabalho para tratamento de saúde bucal. As principais deficiências identificadas no componente Funções do corpo referem-se a mastigar (b5102), funções emocionais (b152) e sensação de dor (b280). No componente Estruturas do corpo, as deficiências mais observadas pelo perito relacionam-se aos dentes (s3200) e gengivas (s3201). As principais dificuldades referidas no componente Atividades e Participação relacionam-se ao cuidado dos dentes (d5201), comer (d550), realizar a rotina diária (d230), fala (d330) e produção da linguagem corporal (d3350). Os principais facilitadores no componente Fatores Ambientais referem-se aos medicamentos (e1101), alimentos (e1100) e ao apoio de profissionais de saúde (e355) e da família imediata (e310). O uso da CIF pode fornecer dados relevantes para a avaliação de resultados de intervenções, necessidades de reabilitação e planejamento das ações de saúde bucal, possibilitando uma melhor compreensão do processo vivenciado pelos indivíduos, bem como sua relação com o bem-estar e a qualidade de vida. / The International Classification of Functioning, Disability and Health (ICF) is a tool to describe the health status and health-related states. The aim of this study was to use the ICF to describe the functioning profile related to work disability due to dental reasons. A total of 41 participants requiring sick leave were evaluated. The main disabilities identified in the component Body functions were chewing (b5102), emotional functions (b152) and sensation of pain (b28010). In the component Body Structures, the main disabilities observed by the expert were teeth (s3200) and gums (s3201). The main difficulties related to the component Activities and Participation were caring for teeth (d5201), eating (d550), carrying out daily routine (d230), speaking (d330) and producing body language (d3350). The main facilitators in the component Environmental Factors were drugs (e1101), food (e1100) and support from health professionals (e355) and immediate family (e310). The use of the ICF can provide relevant data to the outcome evaluation, assessment of rehabilitation needs and oral health planning, conducting to a better understanding of the process experienced by individuals, as well as its relation with the well-being and quality of life.

Rehabilitation outcomes are an important measurement of trauma system effectiveness. However, currently there is no clinically applicable trauma rehabilitation score or framework available to evaluate health and rehabilitation needs after trauma. The World report on Disability (2011) recommended the application of the World Health Organisation International Classification of Function, Disability and Health (ICF) as a framework for all aspects of rehabilitation. A standardised language, based on coded categories would aid in international efforts to evaluate health and disability globally. The ICF framework has not been applied in trauma rehabilitation or trauma systems to date. The objectives were to investigate rehabilitation needs of trauma patients and evaluate to what extent the ICF can be used as a framework to capture and assess health and rehabilitation outcome of patients following traumatic injuries. Two cohort studies with 103 and 308 patients respectively demonstrated the utility of the Rehabilitation Complexity Scale (RCS) in an acute trauma setting. The RCS outperformed other acute measures and rehabilitation complexity correlated with length of stay and discharge destination. A systematic review of 34 articles confirmed that outcome measures frequently used in trauma outcome studies represent only six percent of health concepts contained in the ICF. A quantitative international on-line questionnaire with expert clinicians working in trauma (n=217), identified 121 ICF categories pertinent to rehabilitation and health outcome of trauma patients. Qualitative patient interviews (n=32) identified nearly double the amount of ICF categories (n=234) compared to clinicians. Combined analysis of qualitative and quantitative data presents 109 ICF categories important for rehabilitation and health outcome assessment of trauma patients, using the ICF as a framework. This thesis describes the need for improved outcome evaluation of trauma patients. It demonstrates the acceptability of the ICF language and framework amongst clinicians and suggests the application of the ICF as a framework for trauma service delivery and outcome assessment.

Det finns mycket forskning kring hur individer med Parkinson har möjlighet att förbättra sina fysiologiska funktioner genom träning. Det finns dock få studier som beskriver upplevelser av träningen. Syftet med denna studie var att beskriva upplevelser av sjukgymnastledd gruppträning hos individer med Parkinson och undersöka hur resultatet överensstämde med domänerna i Internationella klassifikationen av funktionstillstånd, funktionshinder och hälsa (ICF). En kvalitativ deskriptiv innehållsanalys tillämpades. Fem deltagare medverkade i studien. En intervjuguide sammanställdes, intervjuerna transkriberades och tolkades. Slutligen sammanställdes resultatet i en tabell med kategorier, subkategorier och koder. Ytterligare en tabell utformades för att redovisa resultatet enligt ICF:s domäner. Det framkom i studien att en sjukdomsspecifik grupp möjliggjorde en trygghet och en social samhörighet. Vidare placerades majoriteten av resultatet inom ICF:s domäner aktivitet/delaktighet samt omgivningsfaktorer, vilket belyste att de psykosociala faktorerna föreföll prägla deltagarnas uppfattningar i större omfattning än de fysiska.