• Gitte Femerling
  • Birgit Bækmann Jeppesen
3 year, Master of Health Informatics (Continuing education) (Continuing Education Programme (Master))
This project is about nursing documentation in home care and arose from our own municipalities’ goal to reduce documentation time considerably. Future home care nursing is characterized by greater demands on skills, the quality of care and treatment of individuals, due to the demographic trends with several older and more chronic patients and the development in health care, which means that treatments can be done at home. There has been a slippage of tasks from region to municipality, and municipalities are co-financiers of hospital admissions in the region. Therefore, there’s a focus on preventative treatment to avoid hospital admissions and readmissions. It requires documentation to plan individual care and treatment processes and exchange data between sectors, but also to document and compare what preventative work is done in local homecare and thereby provide documentation of the quality of the performed care and treatment. KL needs data from the municipalities for economic negotiations but data are not valid. Therefore there’s a strong focus on documentation and registration in home nursing, and KL and the municipalities have performed measurements of performed documentation time.

We had an assumption that “documentation” is not defined in the municipalities and that the documentation time drawn from recorded time or rated by the nurses themselves, contains much more than documenting / recording (lead nursing records and proof of completed care / treatment), because much more is taken in under the concept of "documentation" and that working practices could also be important for documentation time. This was confirmed by a feasibility study in all municipalities throughout the country, and it was also confirmed that many other municipalities are planning to reduce documentation time.

Through methodological triangulation we have performed empirical, qualitative and quantitative studies (questionnaires, field- and time studies and focus group interviews) to enlighten the project's problem:
"What does home nursing work practices and definition of documentation do to documentation time?”
The project is limited ONLY to a study of nurses' definition of documentation, daily work practices / documentation practices, necessary documentation and also documentation time. We have not conducted ourselves as to whether nurses meet all the requirements for documentation: their own, local and external demands.

Data are analyzed in a socio-technical perspective and the results show that there are widely differing definitions of the word documentation among home care nurses, but most nurses include writing, reading information, coordinating patient care, planning the care and scheduling visits, communicating with collaborators, teaching, advising and guiding - in what they register and call documentation. This would definitely affect the overall time of documentation.
Furthermore, there is great complexity in health care work nature, and heterogeneous networks, including all stakeholders, IT systems and other artifacts for documentation. This also has a great influence on documentation practice in home care, and thus also important for documentation time.
We can conclude that it is important to relate to what nurses contain in what they register and call documentation before any talk of reducing the time, but also to study the nurses' work practices to understand the network and thereby improve IT to support and fit into the nature of work as a tool, while generating data for exchange, comparison, evidence and research.
In putting it into perspective we outline further suggestions on what could be investigated deeper, as there are several factors and challenges affecting home nursing documentation practices.
Publication date29 May 2012
Number of pages114
ID: 63426535