Navigating the Complexities of Nursing Documentation When Patients Have Access to the Content: A Qualitative Study.
Birgitte Lerbæk, Kathrine Hoffmann Kusk, Lone Jørgensen and 1 others
PMID 39352005WHAT IT FOUND
Danish nurses described changing how they write when patients can read their records.
They used more objective, non-stigmatising language but often omitted subjective observations or sensitive details. These omissions were shared verbally or via unofficial notes, creating risks for continuity of care and patient safety.
Key findings
01Nurses reported paying greater attention to language, using objective descriptions and avoiding stigmatising or interpretive terms to ensure respect and reduce conflict.
02To avoid triggering conflicts or compromising patient trust, nurses frequently chose not to document sensitive observations, subjective intuitions, or information provided by relatives.
03Nurses resorted to alternative documentation methods, such as verbal handovers, emails, and post-it notes, to share omitted information with colleagues, risking loss of knowledge and continuity of care.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
Read the rest of this summary
You get three full summaries a month, free, and we do not ask for a card. Search, the TL;DRs and your library stay unlimited either way.
What it does not show
The study was conducted in a single hospital in Denmark, so the findings may not transfer to other healthcare systems or countries with different privacy laws or documentation standards. The participants were recruited through a nursing documentation committee, which may have selected nurses who were already engaged with or interested in documentation practices. The study explored nurses' perceptions and experiences; it did not measure actual patient outcomes or safety incidents resulting from these documentation changes. Two focus groups had only four participants, which may have influenced the group dynamics compared to the intended size of five to seven.
Declared interests
The authors declare no conflicts of interest. The study was part of the North Denmark Region's record of processing activities.
The easy way to misread this
Do not interpret the nurses' omission of subjective observations as a failure of professional duty. The study shows this was a deliberate strategy to avoid stigmatising patients or triggering conflict in a new context where patients could read the records. However, this practice creates a significant safety risk by breaking the chain of information between shifts.