Danish Perioperative Nurses’ Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership SUSANNE F. SØNDERGAARD, MLP, RN, SD; VIBEKE LORENTZEN, PhD, RN; ERIK E. SØRENSEN, PhD, MScN, RN; KIRSTEN FREDERIKSEN, PhD, RN ABSTRACT Researchers have described the documentation practices of perioperative nurses as flawed and char- acterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses’ level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses’ documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses’ documentation practices and that a tailored EHR may improve documentation practices. AORN J 106 (July 2017) 31-41. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.05.003 Key words: documentation, electronic health record, Perioperative Nursing Data Set, realistic evaluation, nursing leadership. F or the past 20 years, there has been high demand for increased effectiveness in the Danish health care system. 1 Health care technology is constantly changing, and nurses have faced both explicit and tacit de- mands regarding how to handle and incorporate technology and improve nursing practice. 1-4 The literature suggests that electronic health records (EHRs), which have been imple- mented to document patient-related interventions, are not designed to capture nursing care adequately. 1,2,5 Perioperative nursing documentation is also affected by the poor design of EHRs. Perioperative nurses’ documentation of nursing care has been described as flawed and characterized by subjectivity and poor quality. 6-10 Good-quality documentation of nursing care facilitates continuity and individuality of patient care and helps clarify the nursing process. 11 Furthermore, documenta- tion can enhance the quality of nursing care by providing a record of the patient’s need for care and the patient’s response to nursing interventions. 11-13 http://dx.doi.org/10.1016/j.aorn.2017.05.003 ª AORN, Inc, 2017 www.aornjournal.org AORN Journal j 31