Ohjauksen kirjaaminen : tyypin 2 diabetespotilaiden omahoito ja osaaminen potilasasiakirjoissa
Published in
Studies in sport, physical education and healthAuthors
Date
2017Discipline
TerveyskasvatusThe purpose of this study was to describe the contents of type 2 diabetes patient
self-management counselling documentation, how counselling of self-
management appeared in various content areas and how patients’ self-
management competence developed during the counselling. The research data
consisted of nurses’ documentations from type 2 diabetes patient self-
management counselling situations (N = 60) in primary health care. The data
was collected in 2014 from the period between the years 2005 and 2014. Data
were analyzed using content analysis as well as a case study approach.
The documentation of self-management counselling included entries from
content areas on nutrition, exercise, weight control, substance abuse,
medication, self-monitoring, foot care, mood, and follow-up treatment. There
were no entries related to sleep and rest content areas. The main focus of the
self-management counselling documentation was descriptive entries related to
nutritional discipline and change as well as planning and following medication
care. In the descriptions, patients’ knowledge and skills were described briefly
while their attitudes were described in a number of ways. The support offered
by nurses consisted mainly of giving information. In addition, only in scattered
instances did the patients’ own experiences, understanding, and the application
of their knowledge to practice appear in the entries. Entries made on the
guidance offered in self-management counselling situations consisted of short
references to issues that were handled. They resembled notes more than they
did considerations of patients’ progress in their need to change or evaluations
of changes or competence development from the previous meeting. The overall
guidance of the treatment path seemed illogical and in places even
contradictory because early entries were not returned to. The same issues were
repeated while others remained open.
These findings suggest that self-management documentation should
include the patient`s point of view more often than is currently the case.
Findings are useful for the development of self-management counselling
documentation.
...
Alternative title
Tyypin 2 diabetespotilaiden omahoito ja osaaminen potilasasiakirjoissaPublisher
University of JyväskyläISBN
978-951-39-7079-6ISSN Search the Publication Forum
0356-1070Keywords
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