Documentation in Family Practice – a Qualitative Study

DOI: 10.3238/zfa.2018.0223-0228

german translation / full article

Maria Richter, Steffen Fleßa, Jean-François Chenot, Gesine Weckmann, Annekathrin Haase

Keywords: documentation family practice practice management software qualitative study

Background: Documentation is an important task and duty in the daily practice of family practitioners. So far, documentation in family practice has not been the subject of extensive research in Germany. The aim of this study was to explore the perspectives of family practitioners on the topic of documentation.Methods: This is a qualitative study based on expert interviews with 25 family practitioners, practicing in the region of West-Pomerania-Greifswald, Germany. The interviews were analyzed by content analysis.Results: Main reason for documentation was to track the physicians’ own line of thought. Only few family practitioners emphasized the avoidance of duplicate examinations and their obligation as reasons for documentation. Lack of time and strict legal requirements were named as barriers, with concrete legal requirements largely unknown. With regard to the structure and scope of the documentation, uncertainties and fears were mentioned, especially regarding potential lawsuits. Technical barriers and complex patient cases presented additional challenges. In patient information, documentation was deemed insufficient. Sensitive patient data are often not documented, due lack of trust in confidentiality within the practice team and for the sake of patient protection.Conclusions: There is dissatisfaction with respect to documentation and documentation was perceived as a task of lesser importance. The burden of documentation was considered high in proportion to other requirements. Notwithstanding, the necessity of documentation was accepted by most family practitioners. Better specifications and suitable recommendations for qualitatively good documentation as well as integration of this topic in continuing education and training are necessary.

(State: 14.05.2018)

Latest Issue 9/2020

In Focus

  • Clinical Characteristics of SARS-CoV-2 Tested Patients
  • Urinary Incontinence in Family Practice
  • Challenges in Southern Bavarian Primary Care Practices During the COVID-19 Pandemic