Literature DB >> 24556159

[Audit: medical record documentation among advanced cancer patients].

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


  1 in total

1.  Do Spanish Hospital Professionals Educate Their Patients About Advance Directives? : A Descriptive Study in a University Hospital in Madrid, Spain.

Authors:  María Pérez; Benjamín Herreros; M Dolores Martín; Julia Molina; Jack Kanouzi; María Velasco
Journal:  J Bioeth Inq       Date:  2016-01-21       Impact factor: 1.352

  1 in total

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