There are several methods to carry out a journal review, and the purpose of the journal review may vary.

Collegial Review

The selection is made randomly, for example, people born on the 4th, 14th, 24th day of a month. Collegial review often involves coworkers printing out and anonymizing journals, which a colleague then reviews and provides feedback on. This is to avoid breaches of confidentiality, as only those responsible for a patient/resident have the right to access the journal. The reviewer notes good examples and suggestions for improvement.

Self-check of Journaling

Here, there are different templates for reviewing HSL journals online. When it comes to social documentation, there are often guidelines that describe how social documentation should be conducted in the municipality. Some units have someone who is a documentation officer or quality officer who reviews the journaling and also provides advice and support to colleagues about journaling.

The Red Thread

One way to review the journaling and the collaboration between the different professional groups at the residence is to try to follow the red thread. Are there events or processes that should occur in both patient journals and social documentation journaled in both journals?

Log control

Involves a designated person in the operation, often the operations manager, regularly going in and reviewing who has read which journal and at what time. This is to ensure that no one out of curiosity goes in and reads journals of people they do not have a care relationship with.

Review by MAS (Quality Responsible Nurse)

MAS often gains insight into the journaling in connection with investigations. In addition, MAS can conduct reviews of the journaling. This is often done based on a template to ensure that essential information for safe and secure care is in the journals.

Marker-based Journal Review

SKR has published a book called "Marker-based Journal Review in Home Healthcare" (MJG). Marker-based journal review is based on a strict method and involves a collaboration between doctors and nurses at the specific residence.

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Reflection Questions - Journal Review
Care Staff:
- Does the documentation work well for you and your colleagues?
- If not, what is the cause? Is there anything you can improve?
- Do you ever conduct a journal review?

Manager, Nurse, Occupational Therapist, and Physiotherapist:
- Do you set aside time for journal review?
- Do you have a common structure for how you review documentation?
- How often do you do log checks?
- Would marker-based journal review be something for you?

Resident and Relative:
- Does the documentation seem to work on the unit?
- Do you have to tell the same thing several times?
- Are you given the opportunity to participate in the development of the implementation plan and life story?
- Are you invited to accompany doctor visits?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day