Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators (n = 12) involved in primary care practice and nursing and social educator bachelor’s degree students from a University College (n = 11). Data were analyzed using qualitative content analysis.Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: “Individual factors,” “Social factors,” “Organizational factors,” and “Technological factors.” Each theme also included several sub-themes.Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.

Vitenskapelig publikasjon «Vi har jo blåboka, svartboka og alle listene …» En kvalitativ studie blant pleiefaglig ansatte og studenter om dokumentasjonspraksis i helseog omsorgstjenesten. "We have the blue book, the black book and all the lists…" A qualitative study among nursing staff and students about documentation practice in the health and care service.

BackgroundEffective communication and accurate documentation is critical to delivering quality outcomes and patient safety in municipal elderly care. Yet it is becoming increasingly apparent that healthcare providers struggle to coordinate health information exchange, and are more likely to have inaccurate and incomplete clinical information. The aim of the study was to explore healthcare professionals’ and students’ perceptions of barriers to patient safety and quality in their documentation practice. This knowledge could facilitate the development and implementation of improved documentation practice and information exchange among healthcare professionals.MethodsA qualitative exploratory design with six focus group interviews were used. The study included a purposive sample of nurses and social educators (n = 12) from primary care, and nurse- and social educator students (at Bachelor’s level) (n = 11). The data were analysed by content analysis.ResultsFour main themes about barriers to patient safety emerged from the analysis: “Individual factors”, “Social factors”, “Organisational factors”, and “Technological factors”. Each theme included several sub-themes. A conceptual model was developed to illustrate the relationships between the themes.ConclusionsAccording to the findings, several barriers negatively influence documentation and information exchange and may put the patients in primary care in a vulnerable and exposed situation. To achieve successful documentation, more awareness and effort from the individual professional is required. However, it is critical that primary care services facilitate this through adequate resources, clear missions, and understandable policies.