Development of a new approach to palliative care documentation

Efficient, comprehensive documentation is a vital element of all healthcare provision. It not only provides a record of care, but should reflect the quality of that care, enable continuity of care between practitioners and reinforce care standards. However, documentation in palliative care often falls short of these ideals. This article describes the formulation of an integrated system of documentation which aims to address the failings of documentation procedures in one hospice/palliative care unit. The resulting system seeks to embody the rationale of palliative care within a dynamic, patient-centred approach to nursing documentation.