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Carrying out Electronic Nursing Documentation: Use and Development in Primary Health Care
Linköping University, Department of Social and Welfare Studies, Health, Activity, Care. Linköping University, Faculty of Health Sciences.
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.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1054
Keyword [en]
Communication, electronic nursing, District nurses, nursing diagnosis, documentation, questionnaire
National Category
Nursing
Identifiers
URN: urn:nbn:se:liu:diva-11268ISBN: 978-91-7393-942-3 (print)OAI: oai:DiVA.org:liu-11268DiVA: diva2:17681
Public defence
2008-04-11, K1, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 13:00 (English)
Opponent
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-03-05
List of papers
1. Electronic nursing documentation in primary health care
Open this publication in new window or tab >>Electronic nursing documentation in primary health care
2004 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, 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.

Keyword
district nurse, documentation, electronic patient record, nursing process, audit, primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13018 (URN)10.1111/j.1471-6712.2004.00282.x (DOI)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-08-21
2. Impact of primary care management on nursing documentation
Open this publication in new window or tab >>Impact of primary care management on nursing documentation
2007 (English)In: Journal of Nursing Management, ISSN 0966-0429, Vol. 15, no 6, 634-642 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim was to investigate whether perceptions of electronic nursing documentation and its performance differed because of primary health care management.

Background: Success in leading people depends on the manager's personality, the context and the people who are led. Close proximity to clinical work, with manager and personnel sharing the same profession, promotes the authority to carry out changes.

Methods: This study comprised a postal questionnaire to district nurses and an audit of nursing records from two primary health care organizations, one with a uniprofessional (nursing) organization, and one with multidisciplinary health care centres with general practitioners and/or another profession as managers.

Results: Uniprofessional nurse management increased district nurses' positive perceptions of nursing documentation but did not affect documentation performance, which was inadequate regardless of management type.

Conclusions: Positive perceptions of nursing documentation are bases for further development to a nursing documentation including a holistic view of the patient.

Keyword
district nurses, electronic patient record, nurse management, nursing documentation, primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13019 (URN)10.1111/j.1365-2834.2007.00729.x (DOI)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-08-21
3. Nursing documentation for communicating and evaluating care
Open this publication in new window or tab >>Nursing documentation for communicating and evaluating care
2008 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, Vol. 17, no 16, 2116-2124 p.Article in journal (Refereed) Published
Abstract [en]

Aims: To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care.

Background: As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose.

Design: This study had a cross-sectional descriptive design.

Methods: Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis.

Results: The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care.

Conclusion: Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care.

Relevance to clinical practice: The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritise the development of nursing documentation.

Keyword
communication, documentation, nurses, nursing, primary care, quality
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13020 (URN)10.1111/j.1365-2702.2007.02149.x (DOI)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-05-18
4. Advancing nursing documentation an intervention study using[X]patients with leg ulcer as an example
Open this publication in new window or tab >>Advancing nursing documentation an intervention study using[X]patients with leg ulcer as an example
2009 (English)In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 78, no 9, 605-617 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses experiences of documentation. Method: This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n = 102 and n = 92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention. Result: The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses opinions. Furthermore, the district nurses self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses experiences of documentation in general between the two groups. Conclusion: Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.

Keyword
Nursing records, Community health nursing, Primary health care, Medical records computerized, Wound care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13021 (URN)10.1016/j.ijmedinf.2009.04.002 (DOI)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2017-12-13

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