Carrying out Electronic Nursing Documentation Use and Development in Primary Health Care

University dissertation from Institutionen för samhälls- och välfärdsstudier

Abstract: 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.