Health-care professionals' documentation of wellbeing in patients following open heart surgery: a content analysis of medical records.

AIM

To explore health-care professionals' documentation of patient wellbeing in the first five months after open heart surgery.

BACKGROUND

Open heart surgery (coronary artery bypass grafting or heart valve replacement) is an intervention aimed at relief of symptoms and increased wellbeing. It is a complex procedure with deep experiences encompassing physiological, psychological and social aspects. Health-care professionals' documentation of expressions of decreased wellbeing related to open heart surgery is an important basis for decisions and for the understanding of patients' overall health situation.

METHOD

Eighty medical records were examined by means of qualitative and quantitative methods in order to explore documentation of patient wellbeing at four points in time. The analysis was performed by content analysis and descriptive statistics.

RESULTS

Documentation of physical wellbeing was dominant on all occasions, while psychological wellbeing was moderately well documented and social aspects of wellbeing were rarely documented.

CONCLUSION

The medical records did not adequately reflect the complexity of undergoing open heart surgery. Hence the holistic approach was not confirmed in health-care professionals' documentation.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers need to support and work for a patient-centred approach in cardiac care, resulting in patient documentation that reflects patient wellbeing as a whole.