Aims and objectives. To investigate if, and to what extent, nursing and medical documentation in patients records include entries on cultural background. Background. Health care professionals in Sweden may have difficulties in providing satisfactory care, due to lack of knowledge about immigrants´background. According to Swedish law the information needed to garantee safe care must be specified in the patients´records. It is therefore, important to investigate what information nurses and physicians document on patients´cultural background. Design and methods. In this descriptive study, archival data concerning older and terminally ill patients were analysed retrospectively. The sample consisted of records from 121 patients 65 years or more at the time of the death, who were born abroad and died during the year 1999. Content analysis was used to interrogate data collected from patients records, which related to the patient´s cultural background. Entries (sentences or proportion of sentences) were identified, coded and categorized using Leininger´s Sunrise Model. Results. From the patient records, entries could be related to all factors in the upper part of the Sunrise Model. Some factors were found in all records, and all factors, except technological factors, could be traced across the patients´records. Information concerning folk/lay care could not be found. Conclusion. The results from this study indicate that nurses´and physicians´documentation in patient records included all factors in the Sunrise Model except technological. The overall impression is that the documentation is partly atomistic and insufficient as cultural assessment. Relevance to clinical practice. Even if the health care personnel want to reduce the amount of documentation produced, this study highlighted the importance of documentation on cultural factors. To save time the nursing documentation coukd be based on the Sunrise Model and structured according to the VIPS model.

Syftet var att undersöka om, och i vilken utsträckning sjuksköterskor och läkare dokumenterar uppgifter om patientens kulturella bakgrund i patientens journal. Detta är en beskrivande studie där arkiv data om äldre personer, och personer i terminalt skede analyserades retrospektivt. Urvalet bestod av journaler från 121 patienter, 65 år eller äldre vid tidpunkten för dödsfall som var födda utomlands och som dog under år 1999. Data analyserades med hjälp av innehållsanalys och kategoriserades med hjälp av Leiningers Sunrise model. Resultatet visar att meningsbärande enheter kunde relateras till alla faktorer i övre delen av Sunrise modellen. Några faktorer återfanns i alla journaler, och alla faktorer utom technologiska faktorer återfanns i materialet. Slutsatsen är att sjuksköterskors och läkares dokumentation i patientjournaler inkluderar alla faktorer i Sunrisemodellen utom den technologiska. Det övergripande intrycket är att dokumentationen delvis är atomistisk och otillräcklig som kulturell inventering.