Ohjauksen kirjaaminen : tyypin 2 diabetespotilaiden omahoito ja osaaminen potilasasiakirjoissa

Abstract

The 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.