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In search of details of patient teaching in nursing documentation – an analysis of patient records in a medical ward in Sweden

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  • Febe Friberg
  • Anne‐Louise Bergh
  • Margret Lepp

Abstract

Aim. The aim of this study was to identify terms and expressions indicating patients’ need for knowledge and understanding, as well as nurses’ teaching interventions, as documented in nursing records. Background. Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. Methods. Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients’ need for knowledge and understanding and terms and expressions indicating nurses’ teaching activities were analysed. Results. The results showed that patients’ need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses’ implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. Relevance to clinical practice. Efforts must be directed towards elaborating upon the above‐mentioned terms and expressions as indications of patients’ need for knowledge and nurses’ teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.

Suggested Citation

  • Febe Friberg & Anne‐Louise Bergh & Margret Lepp, 2006. "In search of details of patient teaching in nursing documentation – an analysis of patient records in a medical ward in Sweden," Journal of Clinical Nursing, John Wiley & Sons, vol. 15(12), pages 1550-1558, December.
    • Handle: RePEc:wly:jocnur:v:15:y:2006:i:12:p:1550-1558
    DOI: 10.1111/j.1365-2702.2006.01586.x
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    Cited by:

    1. Krystle Martin & Elke Ham & N Zoe Hilton, 2018. "Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports," Journal of Clinical Nursing, John Wiley & Sons, vol. 27(15-16), pages 3171-3178, August.
    2. Maria Grazia De Marinis & Michela Piredda & Maria Chiara Pascarella & Bruno Vincenzi & Fiorenza Spiga & Daniela Tartaglini & Rosaria Alvaro & Maria Matarese, 2010. "‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital," Journal of Clinical Nursing, John Wiley & Sons, vol. 19(11‐12), pages 1544-1552, June.
    3. Heleena Laitinen & Marja Kaunonen & Päivi Åstedt‐Kurki, 2010. "Patient‐focused nursing documentation expressed by nurses," Journal of Clinical Nursing, John Wiley & Sons, vol. 19(3‐4), pages 489-497, February.

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