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Primary Care Nurses’ Experiences of Structured Documentation: A Qualitative Interview Study
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.ORCID iD: 0000-0003-1549-2469
University of Gävle, Faculty of Health and Occupational Studies, Department of Caring Science, Caring Science. Centre for Research and Development, Region Gävleborg/Uppsala University, Uppsala, Sweden.ORCID iD: 0000-0002-7934-0109
2025 (English)In: Global Qualitative Nursing Research, E-ISSN 2333-3936, Vol. 12Article in journal (Refereed) Epub ahead of print
Abstract [en]

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.

Place, publisher, year, edition, pages
Sage , 2025. Vol. 12
Keywords [en]
structured documentation, nursing, electronic health record, qualitative research, documentation quality, nursing workload, Sweden
National Category
Health Sciences
Identifiers
URN: urn:nbn:se:hig:diva-46821DOI: 10.1177/23333936251330684ISI: 001465308800001PubMedID: 40291462Scopus ID: 2-s2.0-105002706299OAI: oai:DiVA.org:hig-46821DiVA, id: diva2:1954380
Available from: 2025-04-24 Created: 2025-04-24 Last updated: 2025-04-29Bibliographically approved

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Myrberg, Karin

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CiteExportLink to record
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