Sammendrag
Extensive use of paper-based documentation is discovered in spite of the introduction of electronic patient records (EPRs) for at least ten years ago in elderly care. The purpose of the study was to develop knowledge about how shared documentation practices between an EPR and the use of paper-based support systems work in practice and whether this can affect patient safety. We used a focus group interview with an explorative design. We interviewed three staff-groups in three municipalities. Three group interviews were also conducted with nursing students and social educator students. Data were analysed using systematic text condensation. We discovered a widespread use of paper-based documentation as a replacement for, or supplement to, the Electronic Patient Record: Notes, lists, books and EPR-transcripts. The informants perceived this as necessary in order to document and communicate patient information internally as well as between units. The study shows that the EPR system did not fulfil the need for information flow, as the EPR could be either physically unavailable or inadequate. The paper-based documentation was both used to replace or supplement the EPRs. Combined use of paper-based documentation and EPR posed a danger to patient safety, fragmenting the information, and it brought uncertainty as to what the valid information source was. Paper-based documentation could prevent adverse events when EPR was inadequate or unavailable. However, we found that the use of EPR was evolving, and gradually replaced some of the paper-based routines.
Keywords: Computerized Medical Record System, primary healthcare, nursing, documentation, quality and patient safety, adverse events
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