Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative.

Abstract

This paper reports on a quality-improvement project to develop nursing documentation that reflects holistic care within a specialist palliative centre.

The World Health Organization definition of palliative care includes impeccable assessment and management of pain and other symptoms. However, existing nursing documentation focuses mainly on the management of physical symptoms, with other aspects of nursing less frequently documented.

Supported by a project team and expert panel, cycles of review, action and reflection were used to develop a new palliative nursing documentation. The project was divided into three phases: audits of existing nursing documentation, development of a new palliative nursing care document and audit tool, and pilot implementation and audit of the new nursing documentation.

The new palliative nursing care document demonstrated a higher level of compliance in relation to nursing assessments and a more concise, accurate and comprehensive approach to documenting holistic nursing care and recording of patients' perspective.

This project has enabled the consistent documentation of holistic nursing care and patients' perspectives; however, continuous education is necessary in order to sustain positive results and ensure that documentation does not become a 'tick box' exercise. Organisational support is required in order to improve documentation systems.