Documentation in palliative care: Audit on completeness of medical records at a palliative care setting in Sri Lanka

25^th WORLD CANCER CONFERENCE

October 19-21, 2017 | Rome, Italy

M N Vidanapathirana and Gomez D M

University of Colombo, Sri Lanka

Scientific Tracks Abstracts: J Cancer Sci Ther

Abstract :

Introduction & Aim: Medical documentation in palliative care is important for information dissemination within the multidisciplinary team and for medico-legal purposes. This study aimed to assess the completeness of the �Patient Assessment Form� (PAF) within two timeframes at the Palliative Care Clinic, Maharagama and compare them for differences in completeness. Methods: This study was a retrospective internal desk research. All PAFs stored in the clinic were reviewed for two timeframes, which were the first four months since starting the clinic (September-December 2015) and the last four months prior to data collection (October 2016 -January 2017). Data analysis was done with SPSS 23 using descriptive statistics. Results: There were 56 and 42 PAFs for the two timeframes, respectively. In both timeframes, only clinic number showed 100% documentation. In the first timeframe, age (94.6%) was the best documented and psychosocial section was the most poorly documented (48.2%). Reason for referral (55.4%), presenting conditions (60.7%) and problems (73.2%) were inadequately documented. For the second-time frame, primary diagnosis was the best recorded (97.6%) while site of metastases was the worst (59.5%). Documentation of presenting conditions (73.8%) and treatment plan (69%) were insufficient. There was no improvement in overall documentation of PAF with time (p=0.061). However, significant improvements were noted in the documentation of religion (p=0.007) and caregiver information (p=0.002). No difference in documentation between medical and nursing officers was seen for either timeframe (p=0.243, p=0.082). Conclusions: Documentation in the PAF is incomplete. Training health personnel in this regard would improve documentation and care provision.

Biography :

M N Vidanapathirana is a final year medical student currently studying at Faculty of Medicine, University of Colombo. She has completed internships at World Bank Sri Lanka(Health Sector) and Doctors of the World(Médecins du Monde), a French NGO. Her research interests include palliative care, oncology and endocrinology.