Att dokumentera audiologisk rehabilitering - en studie om audionomens arbetsprocess och journalföring
AudionomArbetsprocessAudiologisk rehabiliteringPatientjournalDokumentationAudiologistWorking processAudiological rehabilitationPatient recordDocumentationAudiologi
Audiological rehabilitation is a complex process and can involve medical, educational, psychological, social and technical proceedings. The audiologist's part in this process is essential. The purpose of the study was twofold: to describe the audiologist's working process and to explore patient records written by audiologists according to structure, content and comprehensiveness. Method. Out of rules and regulations, code of ethics and literature concerning audiological rehabilitation from the audiologist's point of view, a model for the audiologist's working process was developed. Intuitive classification formed a general structure, which was filled with content from the literature corresponding to the working process. An audit instrument, based on the presented model, was developed and used in reviewing 85 records written by audiologists from 17 audiological clinics. In all 360 notes were reviewed. The data was analysed by content analysis and emerged from seven areas with altogether 30 aspects. The areas were: formal structure, language, influencing factors, assessment/planning, implementation, evaluation, participation and process. Each aspect was marked and the individual record could achieve a total of 60 points. The result presents the audiologist's working model in words and graphs and shows the complexity of the working process. The result of the review of records revealed severe deficiencies in the practice of the audiologist's documentation and the implementation of current rules and regulations. The total points for the records differed from 8 to 41 with a mean of 24.3. Of the 11 aspects relating to current rules and regulations there were only 4 represented in more than half of the records. Since the majority of the records did not have goals, treatment planning or evaluation according to the goals, they were assumed not to be good for quality evaluation. A clear connection to the audiologist's working process as presented in the model could only be seen in a few records. Implications. In order to follow the law and in striving to be registrated audiologists and enchance the standing of the audiologist profession the documentation ought to be improved, especially in concern with the patient's different status, describing the situations of handicap, goals, treatment planning, psychological implementations and evaluation according to the goals.