Characteristic of person-centered care as documented in medical records at a medical department – a mixed methods

Abstract

Objective: Few studies describe characteristics of content of person-centrered care (PCC) in hospital care. Therefore, this study aim to describe and compare documentation in medical records regarding content of PCC for two diagnostic groups; Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF) at a medical department in a hospital in Sweden.

Methods: Documentation within medical records (n = 121) regarding content of PCC (patient resources, responsibility, i.e. partnership) were analysed by a mixed methods.

Results: The results describe documented healthcare activities (medical records) among patients (COPD¹ = 88; CHF² = 33) treated at medical wards practicing PCC (n = 69, 39¹/30²) and traditional medical wards (n = 52, 49¹/3²). The study showed limited documentation in all medical records regardless of care; however, patients with CHF have higher documentation regarding content of PCC compare to COPD in 6 (symptoms, home situation, objectives, caring activities, patients resources, continuing care) out of 7 areas (planning processes).

Conclusions: To improve healthcare with limited resources, there is need to switch mind-sets from what (diagnosis) to who (resources) using all evidence (expert=scientific to expert=lived experiences) by collecting narratives to facilitate mutual health plans (partnership). This change in healthcare organisation facilitates by transformative and shared leadership to improve teamwork (health professionals, patient, relative) in partnership with all involved.