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Electronic nursing documentation in primary health care
Linköping University, Department of Social and Welfare Studies, Health, Activity, Care. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Welfare and Care (IVV). Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
Linköping University, Department of Social and Welfare Studies. Linköping University, Faculty of Health Sciences.
2004 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318 (print) 1471-6712 (online), Vol. 18, no 3, 310-317 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe and analyse nursing documentation based on an electronic patient record (EPR) system in primary health care (PHC) with emphasis on the nurses' opinions and what, according to the nursing process and the use of the keywords, the nurses documented. The study was performed in one county council in the south of Sweden and included 42 Primary Health Care Centres (PHCC). It consisted of a survey, an audit of nursing records with the Cat-ch-Ing instrument and calculation of frequencies of keywords used during a 1-year period. For the survey, district nurses received a postal questionnaire. The results from the survey indicated an overall positive tendency concerning the district nurses' opinions on documentation. Lack of in-service training in nursing documentation was noted and requested from the district nurses. All three parts of the study showed that the keywords nursing interventions and status were frequently used while nursing diagnosis and goal were infrequent. From the audit, it was noted that medical status and interventions appeared more often than nursing status. The study demonstrated limitations in the nursing documentation that inhibited the possibility of using it to evaluate the care given. In order to develop the nursing documentation, there is a need for support and education to strengthen the district nurses' professional identity. Involvement from the heads of the PHCC and the manufactures of the EPR system is necessary, in cooperation with the district nurses, to render the nursing documentation suitable for future use in the evaluation and development of care.

Place, publisher, year, edition, pages
2004. Vol. 18, no 3, 310-317 p.
Keyword [en]
district nurse, documentation, electronic patient record, nursing process, audit, primary health care
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-13018DOI: 10.1111/j.1471-6712.2004.00282.xOAI: diva2:17677
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-08-21
In thesis
1. Carrying out Electronic Nursing Documentation: Use and Development in Primary Health Care
Open this publication in new window or tab >>Carrying out Electronic Nursing Documentation: Use and Development in Primary Health Care
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Communication of care is essential in the multidisciplinary health care system and the patient record is an important tool for communication. The electronic patient record was introduced to facilitate the documentation of care, as well as the communication and evaluation of care. District nurses met the patient independently of other caregivers at the surgery or in the patient’s home. Documentation by district nurses is assumed to contribute to the view of the patient so that safe care can be carried out in primary health care.

This thesis investigates and analyses the electronic nursing documentation in primary health care with emphasis on the content, district nurses’ experiences of documentation and how the information in the documentation was used. A further aim was to implement and evaluate the effect on standardised nursing documentation, using patients with leg ulcer as an example.

A sample of 239 district nurses, 430 general practitioners and 74 care unit managers answered questionnaires about the nursing documentation and the use of it. One hundred and nine nursing records were audited. Quantitative and qualitative methods were used for data analysis.

Documentation by district nurses lacked clear nursing status, judgment (nursing diagnosis) and nursing goals. Legal requirements were not fulfilled. Medical facts were carefully documented while relevant issues to nursing occurred only seldom. District nurses stated that they were satisfied with their documentation but were in need of education. The focus of the in-service training for documentation was technical rather than involving nursing issues.

Fifty-eight per cent of the general practitioners read the nursing documentation always or often and found it valuable. They had problems, however, finding the information because of the unclear nursing status, the lack of district nurses’ judgement and the large quantity of notes regarding routine activities in district nurses’ documentation.

The nursing documentation was used by 75 % of the care unit managers for evaluating resources and by 51 % for evaluating care. The categories ’prioritisation’, ’inadequate nursing records’, and ’lack of interest’, illustrate for what reasons the care unit mangers did not use the documentation for evaluation of care.

In order to advance district nurses documentation, a standardised nursing wound care record was designed and implemented in nine primary health care centers, with a total of 83 district nurses. Eight primary health care centers were used as a control group, including 56 district nurses. A questionnaire was sent to the district nurses and 102 nursing records were audited before and after implementation. The standardised nursing record improves the descriptions of patient’s health history and status. Nursing diagnoses were more frequently used but were of low quality. Using the standardised nursing wound care record was experienced by the district nurses as being more timeconsuming but also more informative about the patient. Furthermore the knowledge in documentation increased among the district nurses in the intervention group.

Improvement of nursing documentation is necessary in order to obtain documentation that fulfills legal requirements. The managers had a great responsibility to upgrade the documentation, which can be effected by continuing support. Documentation must be seen as a means of transferring information about the patient and of determining whether the best care has been given. A standardised documentation could increase the possibility to compare and determine the value of care. Strengthening the awareness of nursing among district nurses should involve strengthening the documentation, which ought to lead to safer care for the patient.

Place, publisher, year, edition, pages
Institutionen för samhälls- och välfärdsstudier, 2008
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1054
Communication, electronic nursing, District nurses, nursing diagnosis, documentation, questionnaire
National Category
urn:nbn:se:liu:diva-11268 (URN)978-91-7393-942-3 (ISBN)
Public defence
2008-04-11, K1, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 13:00 (English)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-03-05

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Törnvall, EvaWilhelmsson, SusanWahren, Lis Karin
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Health, Activity, CareFaculty of Health SciencesDepartment of Welfare and Care (IVV)Unit of Research and Development in Local Health Care, County of ÖstergötlandDepartment of Social and Welfare Studies
Medical and Health Sciences

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