{"id":9760,"date":"2024-10-11T17:08:08","date_gmt":"2024-10-11T15:08:08","guid":{"rendered":"https:\/\/sygeplejevidenskab.dk\/?p=9760"},"modified":"2025-07-14T20:16:15","modified_gmt":"2025-07-14T18:16:15","slug":"at-navigere-i-kompleksiteten-af-sygeplejefaglig-dokumentation-naar-patienten-har-adgang-til-indholdet","status":"publish","type":"post","link":"https:\/\/sygeplejevidenskab.dk\/index.php\/2024\/10\/11\/at-navigere-i-kompleksiteten-af-sygeplejefaglig-dokumentation-naar-patienten-har-adgang-til-indholdet\/","title":{"rendered":"At navigere i kompleksiteten af sygeplejefaglig dokumentation, n\u00e5r patienten har adgang til indholdet"},"content":{"rendered":"

\"\"<\/p>\n

Download som PDF<\/a><\/p>\n

Birgitte Lerb\u00e6k, Kathrine Hoffmann Kusk, Lone J\u00f8rgensen, Britt Laugesen. Navigating the complexities of nursing documentation when patients have access to the content: A qualitative study. Journal of Advanced Nursing, 2024, epub ahead of print, https:\/\/doi.org\/10.1111\/jan.16502<\/a><\/span><\/p>\n

Introduktion
\n<\/span><\/strong>Sygeplejefaglig dokumentation er en integreret og essentiel del af pleje- og behandlingsforl\u00f8b. <\/span>Her formidles information om planlagt og udf\u00f8rt sygepleje, patienters udvikling og tilstand.<\/span><\/p>\n

Indholdet deles i stigende grad med patienter gennem online platforme, og det kan have betydning for sygeplejerskers dokumentationspraksis. Dette studie udforskede, hvordan sygeplejersker oplevede at dokumentere sygepleje, n\u00e5r patienter har adgang til indholdet.<\/span><\/p>\n

Metode
\n<\/span><\/strong>Seks fokusgrupper med deltagelse af 31 sygeplejersker ansat p\u00e5 sengeafdelinger p\u00e5 somatiske og psykiatriske afdelinger p\u00e5 et universitetshospital i Danmark. Fokusgrupperne blev afholdt i slutningen af 2022 og begyndelsen af 2023. Data blev analyseret via kvalitativ indholdsanalyse.<\/span><\/p>\n

Resultater
\n<\/span><\/strong>P\u00e5 baggrund af analysen fremkom tre temaer:
\n<\/span>(1) At v\u00e6gte sine ord
\n<\/span>(2) At opbygge tillid eller udl\u00f8se konflikter
\n<\/span>(3) At risikere tab af viden.<\/span><\/p>\n

Temaerne illustrerer tilsammen hvordan patienters adgang til indholdet af sygeplejedokumentation kr\u00e6ver, at sygeplejersker navigerer i et komplekst samspil af faktorer, herunder at de har en \u00f8get opm\u00e6rksomhed p\u00e5 sproglige formuleringer, p\u00e5 relationerne mellem sygeplejersker, patienter og p\u00e5r\u00f8rende samt p\u00e5 risikoen for at miste v\u00e6sentlig viden, hvis alternative dokumentations- og overleveringsformer v\u00e6lges.<\/span><\/p>\n

Diskussion og konklusion
\n<\/span><\/strong>Dette studie illustrerer den kompleksitet, som sygeplejersker navigerer i, n\u00e5r patienter har adgang til indholdet af den sygeplejefaglige dokumentation. Selvom bevidstheden om patienters adgang til det skrevne indhold kan fremme et professionelt fokus i sygeplejedokumentation, kan det ogs\u00e5 f\u00f8re til \u00e6ndringer i dokumentationspraksis, som kan kompromittere sygeplejedokumentation som et arbejdsredskab.<\/span><\/p>\n

Implikationer for praksis
\n<\/span><\/strong>Resultaterne fra studiet understreger, at der er et presserende behov for at udforske og diskutere, hvordan f\u00f8lsomme sygeplejeobservationer kan deles p\u00e5 en sikker og passende m\u00e5de, n\u00e5r patienter har adgang til dokumentationen. Desuden kan det v\u00e6re essentielt at prioritere patientinddragelse i sygeplejefaglig dokumentation for at forebygge potentielle misforst\u00e5elser og konflikter med patienter.<\/span><\/p>\n

Birgitte Lerb\u00e6k, sygeplejerske og seniorforsker, Ph.d. <\/span>birgitte.lerbaek@rn.dk<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Download som PDF Birgitte Lerb\u00e6k, Kathrine Hoffmann Kusk, Lone J\u00f8rgensen, Britt Laugesen. Navigating the complexities of nursing documentation when patients 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