Aims and objectives. To present an examination of hermeneutic interpretations statements in documentation; occurrences, nature and significant patterns, before and after the implementation of an electronic patient record and the documentation model quality assurance, problem solving and caring.
Background. The problem-solving and caring model facilitates the systematisation and formatting of nursing documenting in electronic patient record. Text formats are designed for record notes to indicate how the text is to be presented and organised. A narrative text format is designed to facilitate a caring perspective in nursing report notes. This format allows the inclusion of hermeneutic interpretations statements to visualise the understanding of the patient.
Design. Documentation material was examined in a pretest–post-test design.
Method. Report notes were analysed with the aid of Gadamer’s hermeneutic interpretation process. The horizon of interpretation was formed by qualities of caring described in caring philosophy and caring theory.
Results. One hundred and six reports containing hermeneutic interpretation statements reflecting caring were identified. The finding shows that the number of such information is small and decreases during the project.
Conclusion. The result may indicate that hermeneutic interpretation statements in documentation may diminish with the introduction of electronic patient records. This can lead to incomplete information exchange if face-to-face reporting is discontinued. For that reason, electronic patient records need an information structure facilitating information formatted to reflect caring. The use of such a format requires training to a larger extent that was offered during this project.
Relevance to clinical practice. This study might enhance the clinician’s awareness of materialising both analytical and hermeneutical thinking processes in clinical reasoning when documenting nursing care. New documentation tools and routines might favour documentation based on analytical thinking processes with the consequence that essential information of importance for the individual patient’s care might be lost.