About documentation

Shared and clear documentation is fundamental to person-centred care. It is a prerequisite for the ability to utilise the knowledge of both the patient and the professionals and for gaining a shared understanding of the situation and the plan going forward. When everyone has access to the documentation, this also allows follow-up to take place in a satisfactory way.

In order to carry out person-centred work within health and social care, the patient narrative and important agreements between the patient and professionals need to be documented. Documentation has to be done together, by the professionals and the patient, and potentially the patient’s relatives. Medical assessments and results from investigations need to be documented by doctors but preferably together with the patient and their relatives, and always in such a way that patients and relatives are able to understand and potentially voice their opinions.

Currently, patients in many regions can log in to 1177 (A Swedish-government-issued digital plattform for citizens healthcare.) and read their medical records. That places new demands in terms of how we document care. We must include our professional assessments and medical terminology, at the same time as we must write in a way that the patient is able to understand. This also applies when we send out appointment letters or results. The clearer we write, the easier it is for the patient to understand and the easier the partnership and collaboration regarding care and treatment for every individual patient becomes.

The current documentation systems may differ between inpatient care, primary care and municipal social care, and they are usually not adapted to documenting the patient narrative or writing health plans. In order to work in a person-centred way, we still want to create a picture that is as coherent as possible. 

An important step towards working in a way that is more person-centred is including the patient narrative in our notes in the medical record. This prevents the problem of the patient and their relatives needing to repeat themselves and allows information to be easily accessible in one place.  We also want to document notes in a health plan that contains the patient’s short-term and long-term health goals. The health plan should preferably be a part of the medical record, but when this is not possible, we need to find other ways to document this kind of content together with the patient.

With clear and shared documentation, we can better utilise each other’s knowledge and make the patient more active in their healthcare, social care and health.