Transformation of admission interview to documentation for nursing practice

Area of Science:

• Nursing
• Healthcare Documentation
• Patient-Centered Care

Background:

• The admission interview is the initial patient-nurse interaction, crucial for care planning and documentation.
• Effective documentation from admission interviews informs ongoing patient care and communication among nursing staff.

Purpose of the Study:

• To investigate how nurses construct written patient documentation based on admission interviews.
• To analyze the influence of the admission interview process on the content and focus of nursing documentation.

Main Methods:

• A qualitative case study approach was employed.
• Analysis of five taped admission interviews and subsequent written patient documentation by nurses.
• The study was inspired by Ricoeur's interpretive philosophy.

Main Results:

• Nurses' documentation often reflects their own perspectives ('nurse's room') rather than the patient's experience.
• Patients can be objectified in documentation, focusing on 'surgical objects' or 'abnormalities to be medicated'.
• Documentation is influenced by the medical record and nurses' preconceptions of a 'good life'.

Conclusions:

• The VIPS documentation system may function as a framework for nurses' priorities, not necessarily for documenting patient-specific needs.
• Current documentation practices may not fully capture the individual patient's circumstances or their unique encounter with the health system.
• There is a need to re-evaluate documentation systems to ensure patient-centeredness and holistic care representation.