Patient participation in electronic nursing documentation: An interview study among home‐care patients

Abstract

Background: Patients are increasingly expected to take an active role in their own care. Participation in nursing documentation can support patients to take this active role since it provides opportunities to express care needs and preferences. Yet, patient participation in electronic nursing documentation is not self-evident.Objective: To explore how home-care patients perceive their participation in electronic nursing documentation.Methods: Semi-structured interviews were conducted with 21 home-care patients.Interview transcripts were analysed in an iterative process based on the principles of reflexive inductive thematic analysis.Results: We identified a typology with four patient types: 'high need, high ability', 'high need, low ability', 'low need, high ability' and 'low need, low ability'. Several patients felt a need for participation because of their personal interest in health information. Others did not feel such a need since they trusted nurses to document the information that is important. Patients' ability to participate increased when they could read the documentation and when nurses helped them by talking about the documentation. Barriers to patients' ability to participate were having no electronic devices or lacking digital skills, a lack of support from nurses and the poor usability of electronic patient portals. Conclusion:Patient participation in electronic nursing documentation varies between patients since home-care patients differ in their need and ability to participate. Nurses should tailor their encouragement of patient participation to individual patients' needs and abilities. Furthermore, they should be aware of their own role and help patients to participate in the documentation.

Construction and Application of Patient-Participated Health Care Guidance Plan for Patients with Decompensated Hepatitis B Cirrhosis

“…Upon admission and discharge, the anxiety levels of patients in the decompensated phase of hepatitis B-related cirrhosis were assessed using the Self-Rating Anxiety Scale (SAS), 9 and their depression levels were assessed using the Self-Rating Depression Scale (SDS). 9 SAS consists of 20 items, with each rated on a 4-point scale (1)(2)(3)(4). The sum of these items' scores is converted to a standard score by multiplying by 1.25 and rounding to the nearest whole number.…”

“…Similarly, the SDS also comprises 20 items rated on a 4-point scale. (1)(2)(3)(4). The summed scores are adjusted to a standard score in the same manner.…”

“…MUIS consists of three dimensions and 20 items, including ambiguity (8 items), lack of clarity (7 items), and unpredictability (5 items). Each item is rated on a 5-point scale (1)(2)(3)(4)(5), with a total score ranging from 20 to 100. A higher score indicates a stronger sense of disease uncertainty.…”

“…Patient participation focuses on empowering individuals to take an active role in their recovery by engaging in self-management practices that promote health. 4 This approach has been successfully implemented across various healthcare settings, including primary care for patients with multiple conditions, 5 chronic disease management, 6 and elderly care, 7 demonstrating improvements in self-care capabilities and overall quality of life. Despite the recognized value of patient involvement in healthcare, standardized protocols for engaging patients with decompensated hepatitis B cirrhosis in their care are absent.…”

Legal Consistency of Health Personnel in Making Medical Records

“…Electronic medical records help improve patient and community satisfaction (Ranjbar et al, 2021). Patient participation in nursing documentation will result in better adjustments to planning and documentation accuracy (De Groot et al, 2022).…”