| Literature DB >> 24556159 |
Elise Perceau1, Anne Chirac2, Wadih Rhondali3, Murielle Ruer1, Claire Chabloz4, Marilène Filbet1.
Abstract
Medical record documentation of cancer inpatients is a core component of continuity of care. The main goal of the study was an assessment of medical record documentation in a palliative care unit (PCU) using a targeted clinical audit based on deceased inpatients' charts. Stage 1 (2010): a clinical audit of medical record documentation assessed by a list of items (diagnosis, prognosis, treatment, power of attorney directive, advance directives). Stage 2 (2011): corrective measures. Stage 3 (2012): re-assessment with the same items' list after six month. Forty cases were investigated during stage 1 and 3. After the corrective measures, inpatient's medical record documentation was significantly improved, including for diagnosis (P = 0.01), diseases extension and treatment (P < 0.001). Our results highlighted the persistence of a weak rate of medical record documentation for advanced directives (P = 0.145).Entities:
Keywords: audit; medical record documentation; palliative care
Mesh:
Year: 2014 PMID: 24556159 DOI: 10.1684/bdc.2014.1894
Source DB: PubMed Journal: Bull Cancer ISSN: 0007-4551 Impact factor: 1.276