INTERPROFESSIONAL GUIDE to DOCUMENTATION in electonic health records

Abstract

Abstract In the past two decades, the implementation of the electronic health record (EHR) system has been one of the most significant changes to patient care and service delivery in healthcare settings. Interprofessional practice and EHR's, complement each other and are instrumental to providing better care. At a pediatric rehabilitation hospital in Ontario, Canada, an electronic health record project was successfully implemented to strengthen interprofessional care. A focus group was held with eight professional regulatory colleges to build a common understanding of the standards and risks of liability related to interprofessional documentation in the healthcare record. Drawing on literature, Ontario legislation, and the lessons learned from this focus group, the case study that emerges aims to assist students and healthcare professionals in understanding the imperative to engage in interprofessional practice from a regulatory and legislative perspective. This report identifies the challenges associated with developing and implementing this EHR project within the context of a pediatric hospital. The key lessons learned from this experience are presented here to offer students, clinicians, and management a practical demonstration of how regulatory bodies can join the conversation about interprofessional collaboration, as well as offer a preliminary framework for interprofessional documentation in healthcare settings.