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Keywords:

  • documentation;
  • electronic records;
  • grounded theory;
  • nurses;
  • nursing;
  • patient

Aim.  The aim of the study was to investigate what expressions nurses use when documenting patient-focused nursing care in electronic patient records.

Background.  Much effort has been made in the development of nursing documentation. Many studies have found inadequate reporting, focused more on tasks and treatment than on the patient’s voice. Electronic patient record-systems have been introduced, bringing new challenges because of unfamiliarity with computers. Electronic patient records have caused dissatisfaction and frustration, however, some studies show improvement in documentation given enough time and effort. Electronic patient record documentation is an integral part of patient-focused care and thus needs to be investigated.

Design.  The study is based on the grounded theory approach, as developed by Strauss and Corbin.

Methods.  Forty electronic patient records were analysed, considering whether nurses’ written expressions reflected a patient-focused approach. An inductive qualitative method was used, involving constant comparative analysis, up to axial coding.

Results.  Three categories emerged from the data: Patient’s voice: the patient has expressed his/her thoughts, which are written by the nurse, Nurse’s view: the nurse recounts the patient’s own thoughts, state or situation and mutual view in patient–nurse relationship: the documentation describes the patient–nurse relationship.

Conclusions.  This study found that the nursing documentation was patient-focused, to some extent. This is significant because nursing documentation represents much more than simply a record of the continuity of care. Many topics for further studies were presented, e.g., the timing of documentation and the differences between the mode of nursing and the documentation.

Relevance to clinical practice.  The presented findings may be helpful in the development of nursing documentation in electronic patient records and in nursing practice generally. Highlighting the patient’s voice could become an effective tool in nursing and its documentation, saving time and getting clear information for improving the patient’s care.