Clinicians' and nurses' documentation practices in palliative and hospice care

Area of Science:

• Palliative Care
• Health Informatics
• Clinical Documentation

Background:

• Inaccurate health record documentation can compromise patient care, particularly with new tools.
• Challenges in consistent patient-clinician relationships necessitate improved care continuity methods.

Purpose of the Study:

• To evaluate nurses' and clinicians' documentation practices with a new patients' continuation case sheet (PCCS).
• To explore healthcare professionals' experiences using the PCCS for documenting patient information.
• To assess the PCCS's effectiveness in improving continuity of care in palliative care settings.

Main Methods:

• Mixed-methods study combining retrospective case note review (100 patients) and qualitative interviews.
• Quantitative data collected via a structured questionnaire based on the PCCS.
• Qualitative data gathered through face-to-face interviews with palliative care nurses and clinicians, followed by thematic analysis.

Main Results:

• Missing patient information noted in 5-10% of case notes.
• Spiritual, psychosocial, and vital signs documentation deficits observed in 42.6% and 49.2% of records, respectively.
• Poorest documentation occurred in past medical history (40-63% incomplete); interviews revealed challenges, comparisons to previous methods, and adaptation issues.

Conclusions:

• The PCCS is a potentially effective tool for documenting patient information across visits.
• Training is essential to enhance the reliability and validity of PCCS documentation.
• Prioritizing accurate and complete PCCS documentation is vital for quality palliative care; further multi-site studies are recommended.