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Transformation of admission interview to documentation for nursing practice.

Højskov, Ida Elisabeth and Glasdam, Stinne LU (2014) In Scandinavian Journal of Caring Sciences 28(3). p.478-485
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... (More)
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. (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
documentation, admission interview, nurses, communication, transformation.
in
Scandinavian Journal of Caring Sciences
volume
28
issue
3
pages
478 - 485
publisher
Wiley-Blackwell
external identifiers
  • wos:000340288100007
  • other:doi: 10.1111/scs.12071
  • scopus:84905004326
ISSN
1471-6712
DOI
10.1111/scs.12071
language
English
LU publication?
yes
id
a1072672-ff58-4081-a92c-afa64442373b (old id 4125068)
alternative location
http://www.ncbi.nlm.nih.gov/pubmed/24033872
date added to LUP
2013-12-03 12:26:55
date last changed
2017-01-01 03:58:31
@article{a1072672-ff58-4081-a92c-afa64442373b,
  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<br/><br>
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),<br/><br>
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.},
  author       = {Højskov, Ida Elisabeth and Glasdam, Stinne},
  issn         = {1471-6712},
  keyword      = {documentation,admission interview,nurses,communication,transformation.},
  language     = {eng},
  number       = {3},
  pages        = {478--485},
  publisher    = {Wiley-Blackwell},
  series       = {Scandinavian Journal of Caring Sciences},
  title        = {Transformation of admission interview to documentation for nursing practice.},
  url          = {http://dx.doi.org/10.1111/scs.12071},
  volume       = {28},
  year         = {2014},
}