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初级护理护士对结构化文档记录的体验:一项定性访谈研究

Primary Care Nurses' Experiences of Structured Documentation: A Qualitative Interview Study.

作者信息

Dalsten Hjort Anna, Hammar Tora, Myrberg Karin

机构信息

Centre for Research and Development, Region Gävleborg/Uppsala University, Uppsala, Sweden.

Department of Medicine and Optometry, Faculty of Health and Life Sciences, eHealth Institute, Linnaeus University, Kalmar, Sweden.

出版信息

Glob Qual Nurs Res. 2025 Apr 12;12:23333936251330684. doi: 10.1177/23333936251330684. eCollection 2025 Jan-Dec.


DOI:10.1177/23333936251330684
PMID:40291462
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12033446/
Abstract

Healthcare is undergoing an unprecedented technological transition to structured documentation in electronic health records (EHR), which has the potential to increase the quality of documentation. However, given the rising demand for direct transfer of data, there is a risk that requirements for more documentation will follow. This study seeks to investigate primary care nurses' experiences of structured documentation with direct transfer to a national quality registry. Nine primary care nurses using structured documentation in their management of chronic obstructive pulmonary disease (COPD) patients were recruited from different Swedish regions. The semi-structured interviews addressed experiences and work procedures when using a structured documentation template with direct data transfer to a quality register. Interviews were transcribed verbatim and analyzed using qualitative content analysis. Data were framed according to five key concepts; patient safety, time-saving work methods, quality of care, equitable care, and professional autonomy. The nurses experienced some barriers in relation to structured documentation but mainly observed benefits, raising the potential to enhance equitable care and safety for patients with COPD in primary care. Professional experience and autonomy were described as important prerequisites in achieving these benefits. The findings from this study can contribute to strengthening the documentation work procedures of nurses.

摘要

医疗保健正在经历前所未有的技术转型,转向电子健康记录(EHR)中的结构化文档,这有可能提高文档质量。然而,鉴于对数据直接传输的需求不断增加,存在随之而来要求更多文档记录的风险。本研究旨在调查初级保健护士在将结构化文档直接传输到国家质量登记处方面的经验。从瑞典不同地区招募了九名在慢性阻塞性肺疾病(COPD)患者管理中使用结构化文档的初级保健护士。半结构化访谈涉及使用结构化文档模板并将数据直接传输到质量登记处时的经验和工作程序。访谈逐字记录,并使用定性内容分析进行分析。数据根据五个关键概念进行构建;患者安全、省时的工作方法、护理质量、公平护理和专业自主权。护士们在结构化文档方面遇到了一些障碍,但主要观察到了好处,提高了在初级保健中为COPD患者加强公平护理和安全的潜力。专业经验和自主权被描述为实现这些好处的重要先决条件。本研究的结果有助于加强护士的文档工作程序。

相似文献

[1]
Primary Care Nurses' Experiences of Structured Documentation: A Qualitative Interview Study.

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本文引用的文献

[1]
Machine learning and deep learning predictive models for long-term prognosis in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis.

Lancet Digit Health. 2023-12

[2]
Experiences of a Novel Structured Foot Examination Form for Patients With Diabetes From the Perspective of Health Care Professionals: Qualitative Study.

JMIR Nurs. 2023-7-18

[3]
Designing and developing a digital equity dashboard for the emergency department.

J Am Coll Emerg Physicians Open. 2023-6-30

[4]
Electronic health record data quality assessment and tools: a systematic review.

J Am Med Inform Assoc. 2023-9-25

[5]
Extracting Medical Information From Free-Text and Unstructured Patient-Generated Health Data Using Natural Language Processing Methods: Feasibility Study With Real-world Data.

JMIR Form Res. 2023-3-7

[6]
Health professionals' routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study.

BMJ Health Care Inform. 2023-2

[7]
Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle.

Asian J Psychiatr. 2022-11

[8]
The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.

J Med Syst. 2022-5-27

[9]
Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses.

BMC Nurs. 2022-1-28

[10]
Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality.

J Clin Nurs. 2021-6

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