Electronic nursing documentation in primary health care

Abstract

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.

New Technologies and Nursing: Use and Perception of Primary Healthcare Nurses About Electronic Health Record in Catalonia, Spain

“…There are also those that are characterized by a record of events, patient-centered care from birth to death, and have become an indispensable tool for coordination, as it ensures the interaction between all levels of system support and the continuity of care provided by health professionals. 4 At the PHC setting, the EHR is a fundamental information resource. It is the most important document that houses most of the information handled by professionals and health managers at this level of care.…”

Evaluation of the national nursing model and four nursing documentation systems in Finland – Lessons learned and directions for the future

“…Several studies have shown an increased quality of care planning but an increased documentation workload after implementation of an NDS [27][28][29]. In a questionnaire study, including 154 nurses and performed in Swedish primary care by Törnvall et al [30], nurses' opinions on electronic documentation were generally positive. Fogelberg-Dahm and Wadensten [31] found that standardized care plans increased the nurses' abilities to provide consistent high-quality care for all patients, decreasing documentation time as well as redundancy in documentation.…”

Struktur og rutinar, — naudsynte føresetnader for å sikra sjukepleie—dokumentasjonen

“…Alle sjukepleiarane gjev uttrykk for å ha kompetanse på dette området, medan det blant omsorgsarbeidarane/assistentane og hjelpepleiarane syner store manglar når det gjeld å ha kunnskap om korleis dei skal skriva sjukepleieplan i Gerica. Det føreligg funn frå fleire studiar som syner at støtte og utdanningsopplegg kan betra sjukepleiedokumentasjonen [9,[12][13][14]. Nokre av desse studiane har føregått over lang tid, der pre-og post-test av sjukepleiedokumentasjonen syner signifikante forbetringar etter opplaering [11][12][13][14].…”