[Basic registration of risk factors in medical records. Malnutrition, overweight, physical inactivity, smoking and alcohol].

INTRODUCTION

Lifestyle factors are important for clinical outcome. Systematic and early identification of these factors is important in order to offer relevant lifestyle intervention programmes. The objective was to evaluate whether basic registration of risk factors was understandable, applicable and sufficient in the clinical workday.

MATERIALS AND

METHODS

Eleven clinical specialists participated from a broad range of departments. They performed identification and registration of malnutrition, overweight, physical inactivity, smoking and harmful alcohol consumption based on medical records from own departments (in total 2420 times). The specialists then evaluated the understanding, applicability and sufficiency (363 times). Their comments were noted.

RESULTS

Identification and registration was accomplished for 85% (0-100%) of the records. Except for two fields--"measurements of waist" and "other training programs"--the specialists found the basic registration understandable, applicable and sufficient. They lacked more details regarding stress-response in the information material and pointed out inconsistencies in the wording. Ten specialists found that the recommended clinical approach was possible to implement in the present routines.

CONCLUSION

Basic registration of lifestyle factors for adult patients is possible and clinical relevant. It is recommended that the Danish National Board of Health uses the results in future.