In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden.

AIM The aim of this study was to identify terms and expressions indicating patients' need for knowledge and understanding, as well as nurses' teaching interventions, as documented in nursing records. BACKGROUND Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. METHODS Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients' need for knowledge and understanding and terms and expressions indicating nurses' teaching activities were analysed. RESULTS The results showed that patients' need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses' implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. RELEVANCE TO CLINICAL PRACTICE Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients' need for knowledge and nurses' teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.