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Primary Care Nurses' Experiences of Structured Documentation: A Qualitative Interview Study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Research and Development, Gävleborg.
Linnaeus Univ, eHlth Inst, Fac Hlth & Life Sci, Dept Med & Optometry, Kalmar, Sweden..
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Research and Development, Gävleborg. Univ Gävle, Fac Hlth & Occupat Studies, Dept Caring Sci, Gävle, Sweden.ORCID iD: 0000-0002-7934-0109
2025 (English)In: Global Qualitative Nursing Research, E-ISSN 2333-3936, Vol. 12, p. 1-10Article in journal (Refereed) Published
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 Publications, 2025. Vol. 12, p. 1-10
Keywords [en]
structured documentation, nursing, electronic health record, qualitative research, documentation quality, nursing workload, Sweden
National Category
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:uu:diva-555364DOI: 10.1177/23333936251330684ISI: 001465308800001Scopus ID: 2-s2.0-105002706299OAI: oai:DiVA.org:uu-555364DiVA, id: diva2:1955080
Funder
University of GävleAvailable from: 2025-04-28 Created: 2025-04-28 Last updated: 2025-04-28Bibliographically approved

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Myrberg, Karin
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CiteExportLink to record
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Citation style
  • apa
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  • vancouver
  • Other style
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  • en-GB
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  • nn-NB
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  • Other locale
More languages
Output format
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  • asciidoc
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