About shared documentation

Documentation is important in a person-centred care way of working. It safeguards agreements between the patient and the professionals and makes follow-up possible. The documentation is to be based on the patient’s narratives, diagnosis and treatment as well as the plan for their healthcare, treatment and social care.

Traditionally, documentation has involved notes made in the medical records by various professions and has primarily contained medical assessments and the results of tests and investigations. It has also been difficult for patients to read their own medical records. 

In a person-centred way of working, we instead talk about shared documentation. This still includes the professional’s observations, but also the patient’s narrative about their perceptions, experiences, situation and wishes. In order to make this possible, professionals need to take the time to observe and listen and to document the patient narrative as soon as possible after meeting the patient or their relatives. 

It also has to be possible for both the patient and the relevant professionals to read and use the documentation. It is already practically possible for most patients to log in to 1177 (A Swedish-government-issued digital plattform for citizens healthcare.) to read their records. This requires the notes in records and in health plans to be clear so that patients and relatives are able to understand them.

We also want to enable and encourage patients themselves to follow up and update various rehabilitation plans or other goals they have set together with professionals. The more knowledgeable and committed the patient is with the support of a shared and clear documentation, the more effective and preventative the care can become.