Transformation of admission interview to documentation for nursing practice.

Research output: Contribution to journalArticle

Abstract

The admission interview is usually the first structured meeting between patient and nurse. The interview serves as the basis for personalised nursing and care planning and is the starting point for the clinic’s documentation of the patient and his course of treatment. In this way, admission interviews constitute a basis for reporting by each nurse on the patient to nursing colleagues. This
study examined how, by means of the admission interview,nurses constructed written documentation of the patient and his course of treatment for use by fellow nurses. A qualitative case study inspired by Ricoeur was conducted and consisted of five taped admission nterviews,along with the written patient documentation subsequently worked out by the nurse. The findings were presented in four constructed themes: Admission interviews are the nurse’s room rather than the patient’s; Information on a surgical object; The insignificant but necessary contact; and Abnormalities must be medicated. It is shown how the nurse’s documentation was based on the admission interview, the medical record details on the patient (facts that are essential to know in relation to disease and treatment),
as well as the nurse’s preconception of how to live a good life, with or without disease. Often, the patient tended to become an object in the nurse’s report. It is concluded that in practice, the applied documentation system, VIPS, comes to act as the framework for what is important to the nurse to document rather than tool that enables her to document what is important to the individual patient and his special circumstances and encounter with the health system.

Details

Authors
Organisations
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Nursing

Keywords

  • documentation, admission interview, nurses, communication, transformation.
Original languageEnglish
Pages (from-to)478-485
JournalScandinavian Journal of Caring Sciences
Volume28
Issue number3
Publication statusPublished - 2014
Publication categoryResearch
Peer-reviewedYes