Navigating the Complexities of Nursing Documentation When Patients Have Access to the Content: A Qualitative Study

Area of Science:

• Nursing Informatics
• Health Information Management
• Patient-Centered Care

Background:

• Electronic patient records (EPRs) are increasingly accessible to patients.
• This accessibility presents new challenges for healthcare professionals in documenting patient care.
• Understanding nurses' experiences is crucial for optimizing EPR systems.

Purpose of the Study:

• To explore how Danish registered nurses (RNs) experience documenting nursing care in EPRs when patients can access the content.
• To identify the complexities and challenges faced by RNs in this evolving documentation landscape.

Main Methods:

• Qualitative research design utilizing six focus groups.
• Involved 31 RNs from inpatient wards at a Danish university hospital.
• Data analyzed using qualitative content analysis.

Main Results:

• Three key themes emerged: 'weighing one's words,' 'building trust or triggering conflicts,' and 'risking loss of knowledge.'
• These themes highlight the intricate navigation RNs undertake due to patient access to documentation.
• Findings indicate potential impacts on nurse-patient relationships and knowledge retention.

Conclusions:

• Patient access to nursing documentation necessitates RNs managing language, relationships, and knowledge preservation.
• While potentially enhancing documentation focus, it may alter practices, compromising the EPR as a working tool.
• Urgent need to define safe sharing of sensitive observations and prioritize patient involvement in documentation.