50 mins. Documentation Meeting 1 How we are working today Begin Cancel
This is what we will be doing over the course of the next 50 minutes:
Get an introduction to the term Documentation.
Reflect on and discuss Documentation.
Work with the situation map.
Decide what we are going to practise in everyday life.
Group leader reads aloud
Person-centred care is based on three important key terms – partnership, patient narrative and documentation. In this third module we focus on the term documentation. The module encompasses three course sessions and we also have the opportunity to practise and reflect on the material in our day-to-day work in between each session.
When we have completed the module, we will have developed tangible changes to work with in our everyday lives.
Today, during the first course session, we get an introduction to what the term Documentation means within person-centred care. We are also given the opportunity to reflect on how we are currently working with this. Perhaps we will discover opportunities to improve.
Listen together and follow the text below
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.
What was most interesting in this description of Documentation?
What was most interesting in this description of Documentation?
Now we will use the situation map we started working on during the initial meeting. The goal is to understand how person-centred our work is today and what we could change.
We will now look closer at the two assertions under the heading Documentation:
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.
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.
How well do you think these assertions correspond with how we are currently working? Think about the five situations we have chosen to work with and that are set out on the situation map.
We will now work together in the group. We will go through the five situations we have chosen as being the most important in relation to our patients. Discuss each situation, one at a time, on the basis of assertions E and F under the heading Documentation.
We will now focus on assertion E 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.
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.
Tell the others which situation you have chosen to practise ahead of the next meeting and what you intend to do differently.
group leader reads aloud
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. Having a little notebook or notepad in your pocket may be a good aid.
The next time we meet we will tell each other about our experiences.
Good luck!