Abstract
An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland
Highlights
Palliative care is described as the total care of patients in order to achieve the best possible quality of life for patients and their families, encompassing care of body, mind, and spirit [1]
Relevance to clinical practice: An effective system for documentation improves the identification of quality care provided and facilitates individualized care
Overall the findings reveal that the new documentation used on Side A improved the documentation of nursing support and documentation was significantly improved by using a structured document
Summary
Palliative care is described as the total care of patients in order to achieve the best possible quality of life for patients and their families, encompassing care of body, mind, and spirit [1]. Documentation provides a clear picture of; the status of the patient, the actions of the nurse and care outcomes [4]. Healthcare systems are required to manage information to ensure continuity of care and effective information flow and nursing documentation contributes to effective patient care and communication between healthcare professionals and patients [6,7,8]. Quality documentation detailing patients’ issues, nurses’ actions or interventions and patient outcomes is an essential component of professional practice demonstrating high standards of care, where all members of the health care team can be informed of a patient’s status and care [11,12,13,14,15]. Nursing documentation contributes to effective patient care and communication between healthcare professionals and patients through providing a clear picture of; a patient’s status, nurse’s actions and care outcomes. Documentation is often seen as a low priority and often lacks explicit information on patients’; preferences, needs and quality of life
Sign-in/Register to view highlights & summary 
Published Version (
Free)
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call