Abstract

A qualitative study was conducted to understand how social workers document their work in the electronic health record (EHR) in integrated primary care settings. Three themes emerged from the analysis of the focus groups: 1) considerable variability in where and how social workers document their practice within the EHR; 2) EHR functions are not designed for social work practice; and 3) EHR documentation practices as helpful for demonstrating social workers’ contributions to other integrated care team members. Education, training, and EHR adaptations are needed as social workers and other nontraditional healthcare providers continue to partake in team-based service delivery, especially in integrated primary care.

摘要

进行了一项定性研究，以了解社会工作者如何在综合初级保健机构的电子健康记录（EHR）中记录他们的工作。对焦点小组的分析得出了三个主题：1）社会工作者在电子病历中记录其实践的地点和方式存在很大差异；2）EHR功能并非为社会工作实践而设计；3) EHR 记录实践有助于证明社会工作者对其他综合护理团队成员的贡献。随着社会工作者和其他非传统医疗保健提供者继续参与基于团队的服务提供，特别是在综合初级保健方面，需要进行教育、培训和电子病历调整。