Table 1. Coding scheme developed for analyzing the issues reported in the inspection reports.
| Category | Description | Example (translated from Danish) |
|---|---|---|
| Type | ||
| Condition and care* | The patient's diseases, health problems, and care | “In one of three cases, the patient history was incomplete in that a blood clot in the heart, for which the patient received medication, was not documented” |
| Medication* | The patient's current and noncurrent medication | “In neither of the two samples did the prescribed medication correspond to the list of current medication” |
| Consent* | Whether the patient has given informed consent to the care | “In 3 out of 3 samples, it was not documented whether informed consent had been obtained for the care” |
| Risk | ||
| Not existing | Documentation does not exist | “In one out of three samples, it was not possible to retrieve old notes about the care for a wound. Only the present plan could be retrieved as the old plan had been deleted when the care plan had been changed” |
| Not accessible | Documentation is not accessible | “In connection with the implementation of a new IT system, medication was administered without the possibility of checking the administered medication against a medication list” |
| Not read | Documentation is not read | No instances of this risk in the reports |
| Not written / incomplete | Documentation is not written/not updated | “In one of the samples, the problem areas had not been assessed since 2017 [the inspection was made in 2019] and the patient's problem with, for example, dysphagia was not documented” |
| Not procedure compliant | Documentation is not compliant with procedures | “For one patient, an ointment was prescribed without specifying which part of the body to smear and for how long before contacting a doctor again” |
| Inconsistent | Documentation contradicts itself | “There were inconsistencies between the prescribed medication and the medication list in 2 of 3 cases. In one case, an old Marevan prescription appeared on the list of current medication […] In another case the [Marevan] dosage on the medication list was not correct, even though the prescription had been changed more than 1 week before the inspection” |
Note: The institution-level coding of all 893 reports involved only the categories marked with an asterisk (*). The issue-level coding of the 366 issues in the reports that led to demands involved all the categories.