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173 Development of a structured documentation template for shared decision-making in the electronical medical record in the region of Southern Denmark
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  1. Mette Meldgaard1,
  2. Annette Danielsen Jensen2,
  3. Karina Dahl Steffensen1,3
  1. 1Center for Shared Decision Making, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
  2. 2Department of Quality and Patient Safety, University Hospital of Southern Denmark, Aabenraa
  3. 3Institute for Regional Health Sciences, University of Southern Denmark, Odense, Denmark

Abstract

Introduction To foster sustainable SDM implementation it is imperative to integrate SDM process documentation into electronic medical records (EMRs). This documentation should encompass decision scenarios, presented options, identified patient preferences, and state the shared decisions made with patients. Unfortunately, this crucial aspect is often overlooked.

To address this lack of attention to SDM documentation, this project aims to develop a widely supported template for SDM documentation for the EMRs in the Region of Southern Denmark. This, structured documentation template will impact approximately 25.000 health care professionals, influencing EMRs for the 1.2 million citizens in the region.

Methods Two different SDM documentation templates were developed for testing. The template’s usability in the documentation workflow was evaluated through a mixed method research design, employing semi-structured interviews followed by a subsequent survey. Healthcare professionals were sampled from diverse specialties encompassing both mental and somatic healthcare. The subsequent survey is planned to include 400 respondents.

Results The preliminary results include 13 interviews conducted with 7 doctors, 4 nurses, 1 midwife and 1 psychologist. 11 respondents found the template useful in supporting the documentation of the SDM process. Seven out of the 13 respondents favored the same documentation template, while the remaining six had no preference between the two proposed documentation templates. Specific challenges were identified for the nurses in relation to how they could incorporate the two templates into their daily documentation workflow.Results from the patient interview and subsequently survey will be presented at the ISDM conference.

Discussion The documentation templates received broad support across health care groups. However, the results indicate a need for further investigation into the template’s utility in supporting nurses’ documentation workflows.

Conclusion The developed template offers a structured approach to the SDM documentation and ensures documentation of all crucial elements of the SDM process.

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