# Primary Care Nurses’ Experiences of Structured Documentation: A Qualitative Interview Study

## TL;DR

This study explores how primary care nurses in Sweden experience using structured documentation in electronic health records for COPD patients.

## Contribution

The study provides new insights into the benefits and barriers of structured documentation from the perspective of primary care nurses.

## Key findings

- Nurses observed benefits in equitable care and patient safety through structured documentation.
- Professional experience and autonomy were seen as crucial for maximizing the benefits of structured documentation.
- Barriers were noted, but overall the nurses reported positive experiences with the documentation process.

## Abstract

Healthcare is undergoing an unprecedented technological transition to structured documentation in electronic health records (EHR), which has the potential to increase the quality of documentation. However, given the rising demand for direct transfer of data, there is a risk that requirements for more documentation will follow. This study seeks to investigate primary care nurses’ experiences of structured documentation with direct transfer to a national quality registry. Nine primary care nurses using structured documentation in their management of chronic obstructive pulmonary disease (COPD) patients were recruited from different Swedish regions. The semi-structured interviews addressed experiences and work procedures when using a structured documentation template with direct data transfer to a quality register. Interviews were transcribed verbatim and analyzed using qualitative content analysis. Data were framed according to five key concepts; patient safety, time-saving work methods, quality of care, equitable care, and professional autonomy. The nurses experienced some barriers in relation to structured documentation but mainly observed benefits, raising the potential to enhance equitable care and safety for patients with COPD in primary care. Professional experience and autonomy were described as important prerequisites in achieving these benefits. The findings from this study can contribute to strengthening the documentation work procedures of nurses.