Documentation in Child and School Health services Mapping health information from a biopsychosocial perspective using the ICF-CY

Sammanfattning: The overall aim of this thesis was to analyze whether the documentation in the Child Health Services (CHS) and School Health Services (SHS) reflects a holistic view on health as represented by a bio-psychosocial perspective.The method used based on four studies, all with a descriptive design. Analyzed documents contained lists of health terms recommended to be included in the health record (HR) (I), requested information in health questionnaires (II) and the content of free text notes in health records (HRs) (III). A deductive approach was used on an item-by-item basis (I, II), and for the free text notes in HRs a qualitative content analysis with an inductive approach was chosen (III). Nurses’ and physicians’ views on documentation and electronic HR were analyzed with the help of a quantitative questionnaire design (IV).Results showed that information on developed lists of health terms recommended to be included in an electronic version of the HR (I) could be linked to codes in the ICF-CY. The linked health terms were mainly focused on the body, i.e. a biological perspective on health. Several health terms linked to two or more codes, which indicate a need for more clarity in content descriptions. In the locally produced health questionnaires (Study II), for all age groups, a majority of the linked health items counted only once, and involved a psychosocial perspective on health. These health items were related to communication, psychosomatic symptoms and taking care of one’s health (II). The results in the free text notes in HRs (III) mainly focused on a psychosocial perspective on health and were represented across all age groups, but were unevenly distributed. There was new health information in the free text notes which had not been covered in the standardized  part  of  the  HRs. The respective staffs acknowledged that more health information than was documented in the HR was transferred between the CHS and SHS (IV). This information concerned foremost family function. The CHS and SHS had positive opinions regarding the possibilities of an electronic version of the HR.Conclusions: The predominant medical content of lists of health terms was supplemented with health information related to psychosocial health in health questionnaires and in the free text notes in the HR. However, the focus was on the child as a person rather than a child within a family and preschool/school environment, and was strongly related to age groups. More information on children’s health than was recorded was transferred between and within the services. The utility of the ICF-CY as a tool has been confirmed, and indicates challenges to develop a common language to document more on psychosocial health.