Shared documentation

This is what we will be doing over the course of the next 50 minutes:

Get an introduction to the term Shared Documentation.

Share lessons from everyday life.

Discuss improvements.

Decide what we are going to practise in everyday life.

This is the second course session of the documentation module. We get a chance to delve into what is meant by Shared Documentation and share what we have learned with the group. We also have to agree on changes to start working with in our professional practice. 

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.  

During the previous meeting, we each chose a situation where we would practise shared documentation. We focussed on the following assertion:

E. Shared documentation

Our documentation has to capture the patient narrative, their health goals and the medical information in a manner that both the patient and the professionals understand.

Instructions

• Everyone in the group talks about what they thought worked well and what worked less well.
• Those who are listening make notes if there is something that is particularly interesting.
• Divide the time so that everyone is given equal time to talk.

Now we will discuss together how we can become better at shared documentation. What can we start doing differently?

Instructions

• Agree on 3-5 changes that could make a difference. They should be as tangible as possible.
• Write on blue Post-It notes and place on the square on the situation map called Change Plan Documentation.

We will now focus on assertion F under Documentation. You are to individually choose one of our situations and think about what you could do differently considering this assertion in the chosen situation.

F. Health plan

Together with the patient, we decide health goals and the steps needed to get there. These are clearly and understandably documented in a health plan.

Instructions

• Choose a situation in which you think you can make a difference.
• Think about what you can do differently and practise.
• Reflect individually in silence.
• Make notes on Post-Its if necessary.

Tell the others which situation you have chosen to practise ahead of the next meeting and what you intend to do differently.

Instructions

• Divide the time so that everyone has a chance to talk during the six minutes.
• Write down the situation you have chosen and what you are to practise so that you remember.

We now conclude the meeting and the next step is to go out and try new ways of working. Focus on the situation you have chosen yourself but be open to changing other situations as well. Ask someone else in the group for help if you get stuck or are low in energy. Perhaps someone else in the group has good advice. Why not ask patients for help?

Try to note down what works well and whether there are any questions or problems.

The next time we meet we will tell each other about our experiences.

Good luck!