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Psychosocial health information in free text notes of Swedish children's health records.

Ståhl, Ylva; Granlund, Mats; Simeonsson, Rune; Andersson Gäre, Boel; Enskär, Karin.
Scandinavial Journal of Caring Sciences, 27 (3): 616-623 (2013)

DOI: 10.1111/j.1471-6712.2012.01059.x. Information about DOI

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Background: High-quality documentation of children's health is an important priority in health care given trends of declining mental health and reduced well-being in children. There is a lack of information concerning psychosocial health in the standardized part of the national health record in the Child Health Service and the School Health Service in Sweden. Further, little is known if the free text notes in the health record, besides information on physical health, also include information on children's psychosocial health. The aim of this study was to describe what is recorded concerning children's health and development in free text notes.

Methods: The study was based on a retrospective analysis of text using an inductive approach for qualitative analyses of content.

Results: The analysis of the free text notes in the health records yielded seven categories: development, family, health problems, living habits, medical issues, preschool/school and leisure, and well-being. The categories mainly covered psychosocial aspects of health and were not only about health and development problems of the child but also what was covered during the visits. The information was unevenly distributed across the ages. A stronger focus on the youngest age groups within a family and preschool setting is needed. There was novel information in the free text notes such as pain, general health, emotions, mother's mental health and leisure activities, which was not covered in the standardized part of the health records.

Conclusion: The free text notes mainly reflected a psychosocial perspective on health. The findings of this study suggest that requesting more information on children's psychosocial health in the standardized part of the health records could contribute to more comprehensive and informative health records in the Child health Service and the School Health Service in Sweden.

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