Careful Documentation Research Articles

Implementing universal suicide screening in a large healthcare system's hospitals: rates of screening, suicide risk, and documentation of subsequent psychiatric care.

Implementation of suicide risk screening may improve prevention and facilitate mental health treatment. This study analyzed implementation of universal general population screening using the Columbia-Suicide Severity Rating Scale (C-SSRS) within hospitals. The study included adults seen at 23 hospitals from 7/1/2019-12/31/2020. We describe rates of screening, suicide risk, and documented subsequent psychiatric care (i.e., transfer/discharge to psychiatric acute care, or referral/consultation with system-affiliated behavioral health providers). Patients with suicide risk (including those with Major Depressive Disorder [MDD]) were compared to those without using Wilcoxon rank-sum -tests for continuous variables and χ2 tests for categorical variables. Results reported are statistically significant at p < 0.05 level. Among 595,915 patients, 84.5% were screened by C-SSRS with 2.2% of them screening positive (37.6% low risk [i.e., ideation only], and 62.4% moderate or high risk [i.e., with a plan, intent, or suicidal behaviors]). Of individuals with suicide risk, 52.5% had documentation of psychiatric care within 90 days. Individuals with suicide risk (vs. without) were male (48.1% vs 43.0%), Non-Hispanic White (55.0% vs 47.8%), younger (mean age 41.0 [SD: 17.7] vs. 49.8 [SD: 20.4]), housing insecure (12.5% vs 2.6%), with mental health diagnoses (80.3% vs 25.1%), including MDD (41.3% vs 6.7%). Universal screening identified 2.2% of screened adults with suicide risk; 62.4% expressed a plan, intent or suicidal behaviors, and 80.3% had mental health diagnoses. Documented subsequent psychiatric care likely underestimates true rates due to care fragmentation. These findings reinforce the need for screening, and research on whether screening leads to improved care and fewer suicides.

A comparison of synoptic reports and dictated reports to enhance and standardize surgical documentation and quality of care in epithelial ovarian cancer

ObjectiveThe purpose of this study is to assess the degree to which synoptic reports (SRs) and dictated reports (DRs) document elements of the Ovarian Cancer Pan-Canadian Standards Data Elements (OCPCDE) checklist, and to compare their completeness. Analysis of dictated versus synoptic reporting has never been performed for suspected epithelial ovarian cancer (EOC) based on literature review at the time of data collection (1–12). MethodsA retrospective chart review was performed including 254 charts of women 18 years or older, from 2012 to 2017, undergoing surgery for suspected EOC. Charts from five gynecologic oncologists, at a single tertiary care centre were used. The OCPCDE checklist was used to evaluate their completeness. Comparison of completeness between SRs and DRs was done using linear regression with a fixed effect of surgeon to account for intraclass correlation. ResultsThe data showed that SRs included 20.1% more data elements than DRs. Data elements that may be perceived as being more critical were more likely to be documented in SRs. Residual disease data was documented in 51.7% DR versus 99.1% of SR. Descriptive data upon entering the abdomen was more frequently documented in DRs. ConclusionThis study shows that synoptic reporting includes more data elements deemed important by the OCPCDE checklist authors for suspected epithelial ovarian cancer surgery in our centre. We would recommend continuation of SRs in our department, and implementation of synoptic reporting in other gynecologic oncology centres where surgery for suspected epithelial ovarian cancer is performed.

Long-Term Active and Passive Horticultural Therapy Intervention for Elderly Patients with Moderate Dementia and AI Analysis of Medical Records and Care Documents

Background: Previous studies have shown that Hand Care Treatment, a form of passive horticultural therapy, is effective in preventing dementia and MCI and reducing the rate of progression. Due to the Covid-19 pandemic, various activity restrictions were implemented in Japan from March 2020, and the number of elderly people without care and rehabilitation will the number of elderly people without care and rehabilitation has been increasing. Purpose: Progression of cognitive, physical, and mental disability was examined for long-term horticultural therapy study subjects by level of care required. Methods: One subject who had been diagnosed with dementia and was residing in an elderly care facility and consented to a long-term study was selected. In addition to assessments using various evaluation forms, data recorded from time to time, including changes in care plans, were analyzed using text mining methods. Results: This subject tended to progress slowly from 1 to 2 care needs, but progressed from 3 to 5 care needs over a 2-year period. The results of the assessment chart test showed that cognitive impairment and IADL decreased with each increase in the level of care required, but DBD remained the same at the time of admission, even at 5 years of care required. A comparison of HCT and aroma intervention with and without aroma intervention during the nursing care level 1 showed that the improvement in physical, mental, and cognitive function was expected to be higher at the time of intervention. Text-mining inspections have revealed that during the period of nursing care level 1 - 5, active horticultural therapy techniques, and passive horticultural therapy techniques such as HCT and brain rejuvenation aromatherapy were found to betweenness centrality with each other. Conclusion: From the results of mean score of DBD, although the nursing care level has progressed from 1 to a maximum of 5, it can be concluded that the burden of care has not become heavier. There was no tendency for the progression of cognitive impairment in this subject to be faster than in the general AD population, despite the influences of Covid-19. The results indicated that caregiving techniques and active and passive horticultural therapy techniques in Japanese welfare facilities for the elderly are expected to be effective in preventing the progression of cognitive impairment.

Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation.

Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset. Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented. A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001). Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.

Peripheral intravenous catheter-induced phlebitis in a tertiary hospital of Karachi: A cohort study

Purpose: This study aimed to determine the incidence of peripheral intravenous catheter (PIVC)-induced phlebitis and its predictors among adult patients hospitalized at Dow University Hospital, Karachi, Pakistan. Methods: A sample of 258 adult patients admitted in the selected wards and planned for peripheral intravenous catheter insertion were recruited through consecutive sampling during March to May 2019. Daily follow-ups were performed to observe signs of phlebitis using a validated tool. The cohort was followed until discharge, removal of peripheral intravenous catheter, or study conclusion. Results: Of 258 patients studied, 139 (53.9%) were females. A significant number of the participants 104 (40.3%) were young adults of age 20–40 years. The incidence of phlebitis was 39.1%. Tuberculosis (TB), peripheral intravenous catheter dwell time before initial assessment, administration of IV fluids, and dissatisfactory nursing care at Day-1 were associated significantly with the development of phlebitis. There was a doseresponse relationship between the catheter dwell time in hours before initial assessment and the development of phlebitis. Conclusion: This study found an increased incidence (39.1%) in three months of PIVC-induced phlebitis among adult patients. In addition to patient-related and PIVC-related risk factors considered in this study, PIVC-induced phlebitis is found to be significantly associated with the level of PIVC care provided by nurses. Continuous nursing education, developing standard care plans for PIVCs, and proper documentation of care are recommended. Keywords: peripheral intravenous catheter, phlebitis, nursing care, Pakistan

Ensuring of rehabilitation care quality provision: organizational-methodological aspect

Introduction of international treatment protocols into medical care determines the need for scientific substantiation of the mechanisms of their adaptation in rehabilitation care. On the basis of a systemic approach we substantiated the organizational model of quality assurance for the provision of rehabilitation care in health care system in Ukraine, which consists of four interacting subsystems: management, functional, monitoring (resultative) and supply (process) subsystems. The state of rehabilitation care provision in Ukraine at the expense of the Social Insurance Fund of Ukraine and the National Health Service of Ukraine was analyzed. Need to renovate medical and technological documentation of rehabilitation care for the main groups of socially significant diseases that lead to disability of the population was grounded. Recommended program of rehabilitation at the health-resort stage of patients after coronavirus disease (COVID-19) is proposed for health-resort institutions as a methodical basis for the introduction of updated medical-technological standardization documents, which will contribute to improving the quality of rehabilitation care in Ukraine. Typical (recommended) rehabilitation program consists of general provisions on the organization of rehabilitation care, in particular the existing documentary base; indications, contraindications and criteria for admission to the health-resort stage of rehabilitation (in the post-acute or long-term period); diagnostic plan; regulation of actions in case of deterioration of the patient's clinical condition; approximate duration of the rehabilitation course; tasks of the rehabilitation stage; general characteristics of the resort and available natural healing resources; list of rehabilitation procedures; indicators of the effectiveness of rehabilitation care. The program was implemented in a number of health-resort institutions of Ukraine.

Importance of nutritional documentation in maintaining health among the elderly

All individuals have a fundamental human right to nutrition. However, it is well known that undernourishment is a common and major health issue among elderly across the globe. Nutritional documentation helps to guarantee correct nutritional care and therapy. Research on medical and nursing home staff's documentation of nutritional care in hospitals and between medical facilities and nursing homes is scarce. The evidence that is presently offered points to unsatisfactory documenting practices. The nursing workforce lacks the necessary skills to appropriately account for the relationship between patients' medical conditions and their nutritional status, as well as the substantial risk of heightened patient suffering brought on by undernutrition. Unsystematic and unorganized recording processes may contribute to the lack of nutritional information document management and sharing. Another challenge is brought on by the inadequate proper nutrition information transfer when elderly patients are transferring between hospitals and nursing facilities. Clarifying roles in nutrition therapy and treatment is part of interprofessional responsibility. The haziness and ambiguity around accountability may be one factor contributing to the lack of attention given to nutritional documentation. Reassessment of the prevailing systems and development an alternate solution way of tracking food consumption among medical and nursing home residents given the present documentation issues, elevated staff turnover rate, and the inability of training and managing interventions to generate long-term behavioral modifications among nursing home staff may aid in reducing the level of undernutrition and lack of nutrition-related documentation among geriatric individuals.

Legal Consistency of Health Personnel in Making Medical Records

Introduction to The Problem: Medical record is a record or document containing patient identity, examination, treatment, action and other services that must be made by health workers, but not 100% complete medical records. Currently, when talking about medical records, doctors always think, while in the law on health workers, medical records must be made by health workers Purpose/Objective Study: to find out the legal certainty of health workers in making medical records Design/Methodology/Approach: This research is normative with deductive research analysis. Findings: the results of patient records carried out by the medical profession are called medical records, patient records carried out by nurses are called nursing care documentation and patient records carried out by midwives are called midwifery care documentation. Doctors who do not make medical records can get criminal sanctions, while nurses and midwives if they do not do documentation of care will get administrative sanctions . Paper Type: Research Article

A documentation of calcaneus region diabetic foot care: Wound healing during outpatient treatment

Summary: Patients with diabetes are vulnerable to infection and poor healing after injury. Wound care using the steps and techniques described can achieve healing over time. Post healing care instructions are an important part of successful treatment Photos of the wound healing process are a good way to document the effects of treatment and provide a record for the health care team. Such photos can also be used to encourage patients with new wounds to work hard to obey care instructions

Beban Kerja Perawat Berhubungan Dengan Kepatuhan Pendokumentasian Asuhan Keperawatan Di IGD RSUD Kota Bogor Tahun 2022

Introduction: Based on the data obtained from January to May 2022 in the Bogor City Hospital Emergency Room, it was found that the documentation of nursing care was not optimal. 7 Emergency Room nurses said that the workload of nurses was quite heavy with countless patient visits with various criteria. Incomplete documentation of nursing care will lead to a decrease in the quality of nursing services and the occurrence of a problem that has the potential to become a legal case for nursing staff. Therefore, it is necessary to increase knowledge regarding the completeness of proper documentation and motivation from leaders and management so that nurses can complete the documentation of nursing care optimally. Methods: This study uses a cross-sectional descriptive quantitative method, with the type of correlation. The samples taken were 42 respondents. The instruments used were the workload questionnaire from Nursalam and the Hospital Nursing Care Standards (SAK) observation sheet. The dependent and independent variables in this study were Compliance with nursing care documentation and nurses’ workload. Results: The age distribution where nurses were mostly early adults with 33 people (78,6%), and the gender of most of them was 29 people (69%), The distribution of nurses' workload is almost entirely moderate, namely 35 people (83,3%) while the distribution of documentation compliance level is mostly obedient, which is 24 people (57,1%). Correlation Test Results p-value was obtained at 0,031 (&lt; 0,05). Discussion: There is a significant relationship between the workload of nurses and the compliance of nurses' documentation in Bogor City Hospital Emergency Room in 2022.

PENGARUH KOMBINASI MASSASE DAN COUNTER PRESSURE TERHADAP NYERI PERSALINAN KALA I DI WILAYAH KABUPATEN CILACAP

Labor pain is a problem that cannot be overcome until now. Almost all pregnant women experience labor pain. This can result in stress, smooth muscles tighten and blood vessels narrow, uterine contractions decrease and oxygen supply decreases, and uterine ischemia occurs. Counter pressure massage techniques are often used to overcome these problems. However, this technique has not been combined with lumbar massage. So there is a need for further research on this technique. The research design is qualitative with a case study research strategy. The research subjects taken were 3 informants at BPM "N". The research data was taken using observation and direct observation techniques and set forth in the documentation of Varney's care. Then the data is tabulated using domain analysis. The results of this study indicate that there are benefits of massage and counter pressure techniques for active phase I labor pain. The results obtained from the three respondents had the highest score before the intervention was carried out, namely 7. The average pain scale after the action was carried out decreased by 2 points. The conclusion of this study is that massage techniques and counter pressure have a significant effect on the first stage of labor pain.

Recurrent neurotoxity in Naja kaouthia envenomation: A case report from Assam, India

A 35 year old, male patient, bitten by Naja kaouthia with mild pain was admitted in Demow Government Community Health Centre. After 90 min post bite he developed neurotoxic symptoms. As per standard protocol, the patient was treated with 25 vials of antivenom and two doses of glycopyrrolate and neostigmine. Subsequently, he was seemingly devoid of any neurotoxic symptoms and showed signs of recovery. However, after 70 h, the neurotoxic symptoms recurred, and the patient was again treated with an additional 10 vials of ASV along with one dose of glycopyrrolate and neostigmine. Subsequently, the patient recovered completely from all the other symptoms of envenomation. This is the first report of recurrence of neurotoxic symptoms in a patient envenomed by Naja kaouthia in Assam, India and supports the need for greater attention and careful documentation of management of snakebite in the region.

Connection Motivation Work Nurse With Accuracy Charging Documentation Care Nursing at Sundari Hospital Medan

Accuracy in filling out nursing care documentation is important in nursing services, because it will provide legal protection for both the giver and the recipient. Nursing care will reflect the quality of nursing care. The accuracy of filling nursing care documentation is influenced by motivation. From the results of the study the standards of nursing care applied were taken from 30 patient statuses. Can be taken the result of 61.5%. Who performs the standard nursing care that is applied. This study aims to determine the relationship between the work motivation of nurses and the accuracy of documentation of nursing care in the living health care installation at the Sundari Hospital in Medan. This type of research is quantitative descriptive with a cross sectional approach. Samples for the motivation of nurses were taken from 4 living medical care units with a total sample of 30 respondents, and for the accuracy of filling out nursing care documentation, quota sampling was taken. Data was taken using a questionnaire, for the accuracy of filling out nursing care documentation using the ASAK instrument from the Ministry of Health 1997. To determine the relationship between two variables, the Product Moment Correlation Test was carried out with the results of rxy = 0.474 and p = 0.008, which means that there is a significant relationship between nurses' work motivation. with the accuracy of filling out nursing care documentation in the inpatient room at Sundari Hospital Medan.

Automated documentation of almost identical movements in the context of dementia diagnostics

When monitoring the health state of people with neurological diseases, it is crucial to detect disease progression and disease-related changes as soon as possible. Such changes can be detected in the performance of everyday activities like eating, drinking, nose blowing, reading, looking at photos, knitting, telephoning, or brushing hair. In order to supervise such everyday activities, this work proposes an approach employing smartwatches in combination with a Recurrent neural network. A smartwatch offers the possibility of integrating sensor technology into a patient’s daily routines in a unobtrusive way. We have developed a machine learning web tool to track motion data using smartwatch sensors. Data from the accelerometer, heart rate sensor, gyroscope, gravity sensor and position sensor are tracked at 20 Hz. Our tool allows a systematic comparison of the performance between a Long Short-Term Memory (LSTM) model and the different sensor systems in classifying twelve nearly identical daily activities. In this paper, we address the problem of caregiver effort in creating daily care documentation for dementia patients. We present an activity classification system that enables automatic classification of daily activities of patients with dementia across a nursing shift. To assist caregivers, we provide an idea for integrating our system into a nursing documentation. • When monitoring the health state of people with neurological diseases, it is crucial to detect disease progression and disease-related changes as soon as possible. Such changes can be detected in the performance of everyday activities like eating, drinking, nose blowing, reading, looking at photos, knitting, telephoning, or brushing hair. • In order to supervise such everyday activities, this work proposes an approach employing smartwatches in combination with a Recurrent neural network. A smartwatch offers the possibility of integrating sensor technology into a patient’s daily routines in a unobtrusive way. • We have developed a machine learning web tool to track motion data using smartwatch sensors. Data from the accelerometer, heart rate sensor, gyroscope, gravity sensor and position sensor are tracked at 20 Hz. • Our tool allows a systematic comparison of the performance between a Long Short-Term Memory (LSTM) model and the different sensor systems in classifying twelve nearly identical daily activities. • In this paper, we address the problem of caregiver effort in creating daily care documentation for dementia patients. We present an activity classification system that enables automatic classification of daily activities of patients with dementia across a nursing shift. To assist caregivers, we provide an idea for integrating our system into a nursing documentation.

Overlooked and under-evidenced: Community health and long-term care service needs, utilization, and costs incurred by people with severe obesity.

Numbers of people with severe obesity (BMI ≥ 40 kg/m2 ), with need for community health and long-term care (LTC) services, are increasing, but documentation is lacking. We identified individuals with severe obesity known to community health and care professionals in a representative United Kingdom region and used an investigator-administered questionnaire to record needs and use of community health and LTC services. Data were verified against health and LTC records. Local and published sources informed detailed micro-costing. Twenty-five individuals (15 women) consented, aged 40-87 (mean=62) years, BMI 40-77 (mean=55) kg/m2 : 20 participants (80%) were housebound. Twenty-two different cross-sector community health and LTC services were used, including community equipment service (n=23), district nursing (n=20), occupational therapy (n=14), and LTC (n=12). Twenty-four (96%) participants used three or more services, with longest care episode lasting over 14 years. Total annual service costs incurred by participants varied from £2053 to £82 792; mean £26 594 (lower estimate £80 064; mean £22 462/upper estimate £88 870; mean £30 726), with greatest costs being for LTC. Individual costs for equipment (currently provided) and home adaptations (ever provided) ranged widely, from zero to £35 946. Total mean annual costs increased by ascending BMI category, up to BMI 70 kg/m2 . This study provides a framework with which to inform service provision and economic analysis of weight management interventions. People with severe obesity may need sustained care from multiple community care services.

Knowledge and Attitude of Nurses with Computerized Based Nursing Care Documentation

The completeness of the implementation of nursing care documentation is part of the quality of services in hospitals that are influenced by the knowledge and attitude of nurses. This study aims to identify the relationship between the knowledge and attitudes of nurses with the completeness of computerized-based nursing care documentation. This research is quantitative research with a descriptive correlation design and cross-sectional approach. The research population were a nurse at the inpatient unit and outpatient unit of Hospital X North Jakarta. The samples used were purposive techniques with 121 respondents. Univariate analysis of nurse knowledge obtained fewer knowledge data with 40 respondents (33.1%) knowledge of 10 respondents (8.3%) and good knowledge of 71 respondents (58.7%) for attitudes, nurses had less attitude with 57 respondents (47.1%) and good attitude of 64 respondents (52.9%). The results of bivariate research show that: there is a meaningful relationship between the knowledge and attitude of nurses with the completeness of documenting computerized-based nursing care at Hospital X North Jakarta, namely knowledge (p value= 0.000) and attitude (p-value = 0.000). The advice in this study is the improvement and development of training for nurses in implementing computerized-based nursing care documentation. So that the development of science from nurses on computerized-based documentation can be carried out properly.

APLIKASI SOFTWARE ASUHAN KEPERAWATAN INDIVIDU BAGI PERAWAT PERKESMAS DI PUSKESMAS WILAYAH KABUPATEN INDRAMAYU

Public Health Nursing (Perkesmas) is one of the health centers' efforts that supports the improvement of public health status by integrating nursing knowledge/practice with public health through the support of active community participation. Perkesmas service activities can be carried out inside and outside the Puskesmas building. Nurses provide nursing care for individuals who come to the puskesmas, provide family nursing care and nursing care for special groups/health-prone groups in the Perkesmas target area (home visits to vulnerable families).&#x0D; The problem for partners who are appointed in this community service program is the Documentation of Individual Nursing Care in the Perkesmas program which is less than optimal.&#x0D; This program offers solutions that are expected to help solve partner problems. The method used is to develop an application system in the documentation of individual nursing care in the health care program.&#x0D; As a result of this community service program, partners have an application system that will make it easier for community health workers in documenting individual nursing care in the community health program. The results of this program will also be published in accredited national or international journals.&#x0D; &#x0D;

The Influence of the Design of Nursing Care Documentation Design SDKI, SLKI, SIKI (3S) in Hospital Management Information Systems on Nurse Satisfaction at Dian Harapan Jayapura Hospital

The Service is required to be part of the hospital in implementing the documentation of nursing care using computerization. Patients in hospitals often feel dissatisfied with services because nurses take too long to search for patient history data and nurses feel dissatisfied in paper-based documentation which makes the workload increase. The purpose of this study was to design a nursing care documentation design in the 2000s SDKI, SLKI, SIKI (3S) in hospital management information systems on nurse satisfaction. The research method used a research and development design as well as descriptive observational cross sectional with a total sampling technique of 74 nursing respondents at Dian Harapan Jayapura Hospital and analyzed using simple regression analysis. The results showed that 73% of the 3-S nursing care documentation design in SIMRS was in the good category and 77% of nurses were satisfied with the 2000s nursing care documentation design in SIMRS and a significant p-value (0.000) which means that there is an effect of 30.8 % between the design of the 3S nursing care documentation in SIMRS and the satisfaction of nurses at Dian Harapan Jayapura Hospital. It can be said that by increasing the resulting information system, the satisfaction of nurses as users is getting better. It is recommended to hold socialization, training and policy realization for nurses documenting 3S nursing care in SIMRS.

Hubungan Supervisi Keperawatan dengan Kualitas Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap Kemuning dan Dahlia Rsud Waled Kabupaten Cirebon

Supervision is part of the direction of the management function so that all activities are carried out through information obtained by each staff. The implementation of supervision is carried out by supervisors to improve the quality of care by providing guidance, direction, teaching, motivating and improving nursing care in accordance with standard provisions. The purpose of this study aims to determine the relationship between nursing supervision and the quality of nursing documentation of inpatient wards. Kemuning and Dahlia Hospital Waled Cirebon Regency. The research method used was descriptive correlation with a cross sectional approach. The sample of this study was the executive nurse in the inpatient room Dahlia and Kemuning Waled Hospital Cirebon totaling 33 respondents using purposeful sampling technique. The tools used were questionnaires and observation tables, and the data were analyzed using the chi-square test. The results of the study showed that nursing supervision was good 57.6% and the quality of documentation was also good 60.6% after the statistical test resulted in a p value of 0.031 0.05 which showed a significant relationship between nursing supervision inpatient Kemuning and Dahlia Waled Hospital Cirebon district. Implementing and improving supervision activities can make nurses feel that someone is accompanying them, and this will also have a positive impact on the work of nurses on the quality of nursing care documentation.

Existential aspects documented in older people’s patient records in the context of specialized palliative care: a retrospective review

BackgroundDocumentation of older people’s end-of-life care should cover the care given and provide an overview of their entire situation. Older people approaching the end of life often have complex symptoms, live with bodily losses, and face an unknown future in which existential aspects come to the forefront. Knowledge of the existential aspects recorded in palliative care documentation is sparse and merits improvement. This knowledge is relevant to the development of more holistic documentation and is necessary in order to promote reflection on and discussion of documentation of the sensitive existential considerations arising in palliative care. The aim of this study was to describe the documentation of existential aspects in the patient records of older people receiving specialized palliative care.MethodsData were obtained from a retrospective review of the free-text notes in 84 records of randomly selected patients aged ≥75 years enrolled in specialized palliative care units who died in 2017. The notes were analysed using an inductive qualitative content analysis.ResultsThe notes documented existential aspects in terms of connotations of well-being and ill-being. Documented existential aspects were related to the patients’ autonomy concerning loss of freedom and self-determination, social connectedness concerning loneliness and communion, emotional state concerning anxiety and inner peace, and state of being concerning despair and hope. The notes on existential aspects were, however, not recorded in a structured way and no care plans related to existential aspects were found.ConclusionsExistential aspects concerning both ill-being and well-being were sparsely and unsystematically documented in older people’s patient records, but when notes were extracted from these records and analysed, patterns became evident. Existential aspects form an important basis for delivering person-centred palliative care. There is a need to develop structured documentation concerning existential aspects; otherwise, patients’ thoughts and concerns may remain unknown to healthcare professionals.