The importance of documentation in school health care while determining school health care while determining conscript’s fitness for the military serviceMaarit Mäkilä, Harri Pihlajamäki, Mia Mäkinen, Päivi Rautava26.08.2011 NFHK 2011

Background

• In primary health care children and adolescents undergo several

medical examinations in well baby clinics and school health care

• Numerous electronic medical record (EMR) entries are made

• In Finland conscripts’ fitness for military service is determined by

physicians in primary health care, mostly in school health care

• Despite this examination up to 10-15 % of those entering military

service have to interrupt their service due to health problems

Preventive health care

• Grounds for appointment are different from those in nursing or medical treatment

• in Finland guidelines for preventive health care are defined in • in Finland guidelines for preventive health care are defined in Government Degree (380/2009)

• In nursing or medical treatment it is the individual who has symptoms or the disease for which he/she want’s to be treated

Prevention and promotion

• The role of school health care professionals is essential :

• in distinguishing abnormal behaviour and symptoms from the normal developmental process of an child/adolescent at an early stage

• In preventing the marginalisation of children and young people• In preventing the marginalisation of children and young people

• In detecting abnormal development on time and accumulation of risk factors for one individual

• All aspects of wellbeing should be evaluated : physical, psychosocial, emotional, social and school -related

time

Risk factors,symptoms

Aspects influencing schoolchildren’s health and welfare

• Society

• Family

• Frends

• School

• individual development process• individual development process

• Life styles

• Risk behaviour

Studies focused on children/adolescents have shown

• An increase in

• signs of mental symptoms

• signs of social ill health

• psychosomatic symptoms ( for instance headache, backache, tiredness, stomach pain, anxiety)

• Increasing overweight

• Increasing alcohol consumption

School nurses report in a Swedish study(Clausson EK, Köhler L, Berg A. Ethical challenges for school nurses in documenting

schoolchildren's health.

Nursing Ethics 2008 Jan;15(1):40-51.)

• Increasing stress in the schoolchildren’s life

• Increasing subjective health complaints

• Increasing mental problems

• Family and lifestyle factors were considered as important explanatory factors

• The mental and social status of schoolchildren is well known by nurses

• The health check-ups were declared as valid means for assessing the physical health and less valid for assessing the mental health

Documenting, Swedish Study 2008

• majority of the representative sample of Swedish school nurses reported difficulties with documenting ( what to document)

• Mental health problems

• Social health problems

• Family relationships

• Schoolchildren’s behaviour , especially self-harming behaviour

• School situations, problematic relationships with schoolmates and teachers, bullying

• Suspected or verified maltreatment and abuse of various kinds

• Sexuality

Reasons for difficulties in documentation

• Worries about future misinterpretation

• Ethical dilemmas – confidental conversations with the pupil, fear of stigmatizing children

• Practical barries - the layout of EMR is medically focused

• Lack of time• Lack of time

• Difficulties with balancing the demands of confidentiality and those of proper documentation are obvious

Consequences of poor documentation

• Delay in instituting preventive and curative measures

• Decline in the quality of the health care services

• Difficulties while determining health related limitations of the pupil

• choice of careers

• suitability for military service

• driving licence

• Arranging special health care or treatment

The aim of this study

is to find out whether the documentation used in school health care is sufficient from the school physician’s perspective to support a reliable examination of suitability for military service at the age of reliable examination of suitability for military service at the age of 18.

Materials and methods

• Retrospective register-based study

• Turku municipal health care ( 175 000 inhabitants)

• Men eligible for military service in 2006

• Information from each man’s EMR

• Manually collected• Manually collected

• Information about the advanced health examination situation and entries prior to that examination

• Both upper secondary schools and vocational schools, also examinations made in health centres

Results

• 806 evaluations were made ( the whole age group 967)

• 88 physicians

• evaluation range 1-197 per physician

• 53 of the physicians made only 1-2 evaluations ( 9 % of all evaluations)

• 21% (n=166) of evaluations were made by a physician who had under 1 year experience of working in primary health care

Documentation of the advanced health examination

• Entries were made by nurses and physicians

• A good entry was defined according to 7 pieces of information ( the form used, proposed classification, body mass index, smoking, use of alcohol, hobbies, diagnoses sent to military force ):

• 0 : 2 % (n= 17)

• 1 : 7 % ( n= 54)• 1 : 7 % ( n= 54)

• 2 : 25 % (n= 202)

• 3 : 22 % (n= 177)

• 4 : 11 % (n= 89)

• 5 : 19 % ( n= 155)

• 6 : 12 % ( n= 99)

• 7 : 2 % ( n= 13)

Smoking current smoking habits were recorded in EMR in 38% of the cases at the moment of advanced health examination

25

30

35

40

45

thisstudy

NTTT

•NTTT = Adolescent health and

lifestyle survey 2005, 18y men, self

reported

0

5

10

15

20

25

smoking %

NTTT

SHP2006

SHP2008

•SHP = School health promotion

study 2006, 18 y men in upper

secondary school, self reported

•SHP 2008, all students in vocational

schools

SnuffCurrent use 1,24%Earlier recorded information 1,86%

25

30

35

40

45thisstudy

NTTT

•In this study totally in 3 % of the

cases were recorded use of snuff

•NTTT = Adolescent health and

lifestyle survey 2005, 18 y men

0

5

10

15

20

25

use of snuff %

SHPnow

SHPnow/earlier

lifestyle survey 2005, 18 y men

reported snuff experiments now or

earlier

•SHP = school health promotion

study , 2006 upper secondary school

18 y men

Alcoholcurrent use was recorded in 44 % of the cases in advanced health examination

25

30

35

40

45

this

•This study; profuse use or audit over 8 points

• NTTT= Adolescent health and lifestyle survey:- 18 years old men using alcohol at least

once a week:2005: 44 %

0

5

10

15

20

25

alcohol use

thisstudy

NTTT2005

2005: 44 %2007: 41 %

•Results of Audit tests were recorded in 7 % (5 % of the age group scored 8 points or more)

•Earlier information of heavy use but in this examination no recorded information at all : 5 % (n=42) of the whole study group

Audit= alcohol use disorders identification test (WHO)

Illicit drugs

• Recorded information of using/experimenting with drugs ever 4,6 %( n=37) of the cases

• School health promotion study ( National institute for health and • School health promotion study ( National institute for health and welfare):

Upper secondary school education male students reported

2006 : 13 % using/experimenting with cannabis earlier

2006 : 1 % other drugs

Vocational school students reported

2008 : 20 % using/experimenting with illegal drugs

BMI

• Was calculated and recorded in 83 % of the cases

• More over in 7 % of the cases height and weight were recorded, but BMI

was not calculated

• 10 % no records of current height and weight could be found in EMR

• of those whose BMI was recorded/could be calculated :

• BMI 25-29.9 17 %

BMI > 29.9 8 %

• Entering military service 2007:• Entering military service 2007:

18-20 y men BMI 25-29.9 24 %

BMI >29.9 8 %• Nutrition, health risks and health sense among conscripts. Baseline results of VARU intervention study

in the Armoured Brigade and The Kainuu Brigade in 2007. National Public health institute.

• The National FINRISK Study 2007:

25-34 y men BMI 25-29.9 36 %

BMI >29.9 14%

Overweight + obesity

30

35

40

45

50thisstudy

Varustudy

•Measured :

•This study, 2006, 18 y men

•Varu study, 2007, 18-20 y men

•Finnrisk study, 2007, 25-34 y men

•Self reported overweight:

0

5

10

15

20

25

30

bmi over 25

Finnriskstudy

SHPuppersec.

SHPvoc

•Self reported overweight:

•School health promotion study:

•upper secondary school

- 2006 total 13 %

- 2010 boys 16 %

•Vocational school

- 2008 total 21 %

- 2010 boys 25 %

Other aspects recorded

• Family problems

• recorded entries 5,5 % (n= 44)

• School problems:• School problems:

• Attending special education school 7,8 % (n= 63)

• Some arrangements in pupil’s own school 2 % ( n= 16)

• Recorded issues of discussing the pupil’s matters in pupil welfare working group: 8 % ( n= 64)

Other aspects recorded

•Bullying ever

•Recorded in EMR 8 %

(n= 64)

•Hobbies

•Current information recorded

46 %

•Physical exercise 29 %

(n= 236)

•6-8 % report weekly experiences of bullying in questionnaires

(n= 236)

•Some other hobby 0,75 %

( n=6)

•No physical exercise16 %

(n= 131)

Psychiatric care now or earlier, recorded in EMR

• In a spesialized clinic 8 % ( n=66)

• In primary health care 7 % (n=59)

• In family services 0,74% ( n=6)

• In family services visit about 1200 different families per year • In family services visit about 1200 different families per year

• Approximately 20-25 % of adolescents suffer from mental disorders ( several Finnish studies)

Conclusions

• Documentation was scarce

• Health risk factors and promotive factors are poorly recorded in EMR

• In particular the gathering of risk factors longitudinally is difficult

• We need more reseach on and guidelines for preventive health care and especially for documentingcare and especially for documenting

• The importance of documentation needs emphasizing

• Current EMR systems do not sufficiently support especially preventive health care documentation

Answer to reseach question

• There is probable lack of recognizing especially mental and social risk factors

• There is definitely lack of proper documentation so that cumulation of problems can be easily detectedof problems can be easily detected

• For the physician it’s quite a challenge to evaluate suitability for military service in a reliable way

Thank you!