Simplifying the care plan documentation procedure – An interview study with nurses at a medical ward at a university hospital in Sweden

Abstract

Objective: Swedish healthcare is experiencing an ongoing change from a biomedical perspective to person-centered care (PCC). Therefore, a transition in documentation of assessment, care and treatment is needed. The aim of this study was to describe nurses' experiences with care plans at a university hospital medical ward in Western Sweden. Methods: Six semistructured interviews were conducted with nurses, and the data were analyzed using a qualitative content analysis with an inductive approach. Results: Nurses' experiences with working with care plans were described as improving patient safety and included the following three subcategories: managing a high workload, collaboration improves documentation and creating structure in the medical records. In summary, nurses highlight a lack of time and team collaboration as important denominators in creating conditions for mutual care plans. Conclusions: Working with care plans is an important part of a nurse's work. Procedure, use of documentation and ensuring regular revision all influence the quality of care due to the simple and clear structure of documentation within the medical record. To strengthen the patient's involvement in a mutual care plan, nurses play a key role in implementing PCC, which is a tool used to improve partnerships between patients and health professionals.

Documentation of pressure ulcers in medical records at an internal medicine ward in university hospital in western Sweden

“…Therefore, it is important for all staff members to prevent pressure ulcers among patients (Bluestein & Javaheri, 2008; Ferguson et al, 2019; Gunningberg et al, 2015; Jackson et al, 2019; Kaşıkçı et al, 2018), in line with professional ethical codes for RN (ICN, 2021) about health and well‐being. In summary, systematic use of Green Cross (Schwarz et al, 2021) and simplifying a structured the documentation procedure (Larsson et al, 2019) of medical records (EPUAP/NPUAP/PPPIA, 2019) is highly recommended to prevent pressure ulcers, especially among the elderly (Khor et al, 2014).…”