How to distinguish double documentation from documentation of distinct data

Gert Galster, MD MI

SHI-2011

August, 2011

Abstract

Within health informatics, it has for years been an objective to substitute double documentation of health data with data reuse. The elimination of double documentation potentially reduces unnecessary, additional work, and thereby releases human resources. To meet these potentials it is necessary to have a clear delineation of the involved concepts as well as a method to distinguish between double documentation and documentation of distinct data. With the incidence of double documentation in Danish health registries as a starting point and on the basis of a qualitative literature review, the present paper explores the meaning of double documentation and proposes a definition. With clinical examples and the proposed definition, key issues for the distinction between double documentation and documentation of distinct data are highlighted, and it is argued that the identification of double documentation necessitates a semantic analysis of the registered data.

Citation

Galster G. How to distinguish double documentation from documentation of distinct data. In: Fensli R, Dale JG, editors. SHI2011 Proceedings : 9th Scandinavian Conference on Health Informatics, 30 August 2011. Oslo, Norway: TAPIR Akademisk Forlag; 2011. p. 16-20.

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