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Compliance between registered nurses’ clinical judgment and documentation in homecare for older patients with COPD: A multiple case study
Centre of Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway.ORCID iD: 0000-0002-4808-7956
Centre of Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway.
University of Gävle, Faculty of Health and Occupational Studies, Department of Caring Science, Caring Science.
Centre of Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway.
2023 (English)In: Nordic journal of nursing research, ISSN 2057-1585, E-ISSN 2057-1593, Vol. 43, no 1, p. 1-8Article in journal (Refereed) Published
Abstract [en]

Registered nurses (RNs) play a crucial role in the clinical judgment (CJ) and documentation of the health conditions and the healthcare of patients diagnosed with chronic obstructive pulmonary disease (COPD). Using a multiple case study approach, the aim of the present study was to explore and describe RNs’ CJ in homecare visits for older patients with COPD as they appeared in the electronic patient records (EPRs) and how well the content corresponded to what the RNs explained verbally was important to report. Data were collected through observations of 16 homecare visits, interviews with RNs, and retrospective reviews of EPRs. The study is reported in accordance with COREQ. Quantitative and qualitative content analysis revealed that the RNs’ CJs in homecare visits were represented only to a small extent in the documentation in the EPRs. The documentation was mainly about procedures and tasks performed and did not correspond to what the RNs explained verbally was important to report. This knowledge contributes to improvements to ensure patient safety in this research field.

Place, publisher, year, edition, pages
SAGE , 2023. Vol. 43, no 1, p. 1-8
Keywords [en]
content analyses; electronic patient record; home healthcare; nursing; older adults
National Category
Health Sciences
Research subject
Health-Promoting Work
Identifiers
URN: urn:nbn:se:hig:diva-41237DOI: 10.1177/20571585221149865Scopus ID: 2-s2.0-85150432613OAI: oai:DiVA.org:hig-41237DiVA, id: diva2:1745966
Available from: 2023-03-27 Created: 2023-03-27 Last updated: 2025-10-02Bibliographically approved

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Enmarker, Ingela

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