How are allied health notes used for inpatient care and

clinical decision-making? A qualitative exploration of

the views of doctors, nurses and allied health
professionals

T.Pain, BSc, PhD (2016)

Background:

Inpatient care is dependent upon the effective transfer of clinical

information across multiple professions. However, documented
patient clinical information generated by different professions is not
always successfully transferred between them. One obstacle to
successful information transfer may be the reader’s perception of the
information, which is framed in a particular professional context,
rather than the information per se.

Objective:

The aim of this research was to investigate how different health

professionals perceive allied health documentation and to investigate
how clinicians of all experience levels across medicine, nursing and
allied health perceive and use allied health notes to inform their
decision-making and treatment of patients.

Method:

The study used a qualitative approach. A total of 53 speech

pathologists, nurses, doctors, occupational therapists, dieticians and
social workers (8 males; 43 females) from an Australian regional
 tertiary hospital participated in eleven single discipline focus groups,
conducted over 4 months in 2012. Discussions were recorded and
transcribed verbatim and coded into themes by content analysis.

Findings:

Six themes contributing to the efficacy of clinical information

transference emerged from the data: day-to-day care, patient
function, discharge and discharge planning, impact of busy
workloads, format and structure of allied health documentation and a
holistic approach to patient care.

Discussion:

Other professions read and used allied health notes albeit with
differences in focus and need. Readers searched for specific pieces
of information to answer their own questions and professional needs,
in a process akin to purposive sampling. Staff used allied health notes
to explore specific aspects of patient function but did not obtain a
holistic picture.

Conclusion:

Improving both the relationship between the various health

professions and interpretation of other professions’ documented
clinical information may reduce the frequency of communication
errors, thereby improving patient care.
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