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At least 127 records · Page 7Linked to original sources
PubMed1997

Impact of a statewide trauma system on rural emergency department patient assessment documentation. OHSU Rural Trauma Research Group.

OBJECTIVE: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in > 1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. CONCLUSION: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.

Adolescent↗
PubMedDate not supplied

Documentation of patient care services in a community pharmacy setting.

OBJECTIVE: To assess the types of patient care documentation systems currently being used by community pharmacists and determine the preferred characteristics of an ideal patient care documentation system. DESIGN: Mailed survey. SETTING: United States. PARTICIPANTS: One pharmacist from each of 125 targeted community pharmacies. INTERVENTION: Survey mailed in February 2003, followed by a second mailing to nonrespondents in March 2003. MAIN OUTCOME MEASURES: Responses to survey items about (1) patient care services provided at the pharmacy, (2) characteristics of the current documentation system, and (3) characteristics of an ideal documentation system. RESULTS: A total of 48 usable responses were received from 106 pharmacies to which surveys were delivered (45.3%). Independent pharmacies accounted for 50% of survey respondents. More than 80% of respondents were providing patient screening or management services associated with a chronic disease such as diabetes, hypertension, or dyslipidemia. Approximately 54% of the pharmacists were using a paper documentation system. However, challenges identified with a paper system included documentation time, retrieval of patient data, tracking patient outcomes, and storage. Respondents indicated that an ideal documentation system would be comprehensive, easy and efficient to use, and affordable. CONCLUSION: Pharmacists recognize the importance of documenting patient care services. While the majority of respondents are using paper charts to document patient care services, computerized systems appear to offer advantages over paper charts. This information offers community pharmacists a summary of previous experiences and a starting point when trying to identify or modify a documentation system that would better meet the pharmacies' needs.

Community Pharmacy Services↗
PubMedDate not supplied

Documentation and coding of medical records in a tertiary care center: a pilot study.

BACKGROUND: Since the medical record is the major source of health information, it is necessary to maintain accurate, comprehensive and properly coded patient data. We reviewed 300 medical records from patients at King Faisal Specialist Hospital and Research Center, representing four departments (medicine, surgery, pediatrics and obstetrics and gynecology). METHODS: The records were audited following the guidelines of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures performed. RESULTS: Of 1051 items abstracted, 876 (83.3%) were accurately documented, 41 (3.9%) were inaccurately documented, and 134 (12.7%) were not documented. Of the items abstracted, 736 (70%) were assigned a correct code, 110 (10.5%) were assigned an incorrect code, and 205 (19.5%) were not coded. More items classified as accurately documented were coded correctly (71.1%) than items inaccurately documented (49.7%) (P < 0.0001). The difference in comprehensiveness of documentation, which reflects physician performance, was not statistically significant among the four departments (P value < 0.234). The difference in the accuracy of coding, which reflects coder performance, was statistically significant (P value < 0.036). CONCLUSIONS: Only 60% of the audited records met the benchmark for good quality medical records with regards to documentation and coding. A positive correlation between the accurate documentation and correct coding was noted, which supports the conclusion that high quality documentation enhances coding accuracy. These data, although encouraging, suggest room for improvement, which can be achieved through the collaboration of clinicians, who have extensive clinical experience, and coding professionals, who have comprehensive classification system expertise.

Documentation↗
PubMedDate not supplied

Digitization of medical documents: an X-Windows application for fast scanning.

This paper deals with digitization, using a commercial scanner, of medical documents as still images for introduction into a computer-based Information System. Document management involves storing, editing and transmission. This task has usually been approached from the perspective of the difficulties posed by radiologic images because of their indisputable qualitative and quantitative significance. However, healthcare activities require the management of many other types of documents and involve the requirements of numerous users. One key to document management will be the availability of a digitizer to deal with the greatest possible number of different types of documents. This paper describes the relevant aspects of documents and the technical specifications that digitizers must fulfill. The concept of document type is introduced as the ideal set of digitizing parameters for a given document. The use of document type parameters can drastically reduce the time the user spends in scanning sessions. Presentation is made of an application based on Unix, X-Windows and OSF/Motif, with a GPIB interface, implemented around the document type concept. Finally, the results of the evaluation of the application are presented, focusing on the user interface, as well as on the viewing of color images in an X-Windows environment and the use of lossy algorithms in the compression of medical images.

Database Management Systems↗
PubMed2006

Discursive practices in the documentation of patient assessments.

AIM: This paper reports a study analysing the various functions of nurses' documentation of patient assessments. BACKGROUND: Modes of documentation have received much attention in the nursing press since the integration of the nursing process and nursing models. Previous research has shown that current documentation practices do not consistently promote effective communication and evaluation of patient care. A recent systematic review found no evidence that any particular system of documentation improved this situation. However, nurses' documentation serves not only to communicate information to others, but also has a political function as a presentation of what is important and ethically 'right' to report. METHOD: A Foucauldian approach to discourse analysis was used to analyse 45 patient records. FINDINGS: The findings indicate that nurses employ three discernible discursive practices in the documentation of patient assessments: medical, nursing and informal. Each practice has an effect on the presentation of nursing in the documentation. Because of the complex interplay between these practices, nurses present themselves as aligned with the medical profession, as distinct and professional, and as informal in their descriptions of non-biological information. The use of these practices appears to be motivated by the type of information being reporting. CONCLUSION: Existing literature highlights the functional aspects of nursing documentation. In contrast, this paper explores the way in which nurses, through their documentation, constitute themselves and the nursing profession. In this way, nursing documentation is viewed as a social practice and a conduit through which particular power effects are produced and reproduced, rather than simply a matter of, for example, knowledge, individual choice or good practice.

Attitude of Health Personnel↗
PubMed1990

The relationship of attitude, subjective norm, and behavioral intent to the documentation behavior of nurses.

Ajzen and Fishbein's theory of reasoned action was used to assess the relationship of nurses' attitude, subjective norm, and behavioral intention to their documentation behavior. Attitudes, subjective norms, and behavioral intentions toward documentation were elicited from 108 staff nurses. Documentation behavior was based on what should be documented in any hospitalized patient's chart during a shift. This exploratory model was analyzed with LISREL VI. The overall fit of the final model to the data was good, as judged by a chi-square (df = 7, p = .845). The total coefficient of determination for the structural equation was .461. Attitude toward documentation did not relate significantly to intention to document optimally. Subjective norm did have a significant effect on behavioral intent. Attitude and subjective norm accounted for 46.1% of the variance in behavioral intent. Behavioral intent had a significant effect on documentation behavior, accounting for 15.2% of the variance. It appears that subjective norm, which is the influence of others, is what directs the intention to document and thus relates to subsequent documentation. Recommendations for practice include the communication of high ideals and expectations of important others to the staff nurse in order to improve the quality of documentation.

Attitude of Health Personnel↗
PubMed2000

[Using an anesthesia information management system (AIMS) for documentation in a day care unit for ambulatory surgery].

UNLABELLED: From January 1997 until June 1999, the complete durations of stay of 3152 outpatients were entered into a computerized documentation system. The scope of the data entry went from patient admission to patient release. The objective was to determine the usefulness of the anaesthesia information management system (AIMS) in producing complete and high-quality documentation in the field of outpatient operations. Some aspects and results from routine work are presented here. METHOD: The system was installed in eight bedside computers, in addition to a further client connected to the existing AIMS via Ethernet. Patient medical courses were documented both preoperatively and postoperatively in outpatient bedsides until their discharge or admission. The online documentation software NarkoData (Version 4, Imeso GmbH, Hüttenberg, Germany) was used to document and store patient data in a database. This program contains all relevant information concerning the course of anaesthesia and outpatient duration of stay, including application of drugs, vital signs, observation times, and medical findings as well as the data sets of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), ICD, and ICPM. Data was analyzed by exporting from the database into a statistical program using "structured query language." RESULTS: Data sets of 3152 outpatients were entered into the online documentation software. Most (54.2%) of the ambulatory surgical procedures were performed by the Department of Traumatology. General Surgery followed with 16.0%, and Urology managed 9.5% of the cases. The most frequent ambulatory surgical procedures were: diagnostic arthroscopy (923, 31.2%), removal of osteosynthetic material (410, 13.8%), and circumcision (250, 8.4%). Anesthesia procedures consisted of inhalative (38.6%, n = 1218) and intravenous anesthesia (IVA) (29.9%, n = 938). In 22.6% (713) of the cases, regional anaesthesia was performed. The average postoperative observation time was 289.2 +/- 140.1 minutes. One hundred sixty-nine patients (5.4%) were unexpectedly admitted to overnight care. The decision to admit patients to normal wards took place within the first 3 postoperative hours in 51.9% of the cases. CONCLUSION: The AIMS described above is sufficient in documenting the entire care process of patients in a day care unit. Integration into the existing AIMS was an important prerequisite for the integrity of the documentation chain. This allowed for a sensitive communication with other clinical data processing systems. The quality of documentation and flow of information at the workplaces in the day care unit were increased, similarly to other anaesthesiological workplaces in the hospital. Medical and administrative data and information for analyses of clinical processes are possible with such tools.

Adult↗
PubMed2006

Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record.

OBJECTIVE: The aim of the study was to describe a paper-based, template-driven and an electronic medical record used for capturing emergency care clinical information and to compare the accuracy of these documentation systems for coding patient encounters using the American Medical Association Current Procedural Terminology-2004 (AMA CPT-2004) evaluation and management codes intended for provider reimbursement. METHODS: A retrospective, cross-sectional study of 4-consecutive-day samples of ED patient encounter records from 2 similar community hospitals was done. For clinical documentation, hospital A uses an electronic medical record, whereas hospital B uses a paper-based template-driven record. Using a simple analytic model, expert coders A and B, respectively, coded the records from hospitals A and B for completeness. First, power analysis determined the acceptability of the patient record sample sizes (1 - beta = .90 at 1% significance level), and the frequency of AMA CPT-2004 primary evaluation and management codes 99281 through 99285 was calculated. Second, the completeness discrepancy rates for hospitals A and B were compared to determine the accuracy of both the paper-based, template-driven record and the electronic medical record in documenting and representing the clinical encounter. Third, interrater reliability between expert coders A and B was calculated to assess the level of agreement between each expert coder in determining the completeness discrepancy rates between hospitals A and B. Finally, the frequency of primary evaluation and management codes was analyzed to determine if there was a statistically significant difference between the paper-based, template-driven record and the electronic medical record representation of the clinical information, and if that difference could be attributable to the differing clinical documentation systems used in hospitals A and B. RESULTS: First, descriptive display demonstrated a difference in the frequency of the primary evaluation and management codes 99283 and 99284 within hospital A (expert coder A assessment, 36.1% vs 39.1%; expert coder B assessment, 36.6% vs 38.7%) and hospital B (expert coder A assessment, 47.8% vs 21.9%; expert coder B assessment, 48.6% vs 21.4%) was noted with the median, primary evaluation, and management code for hospital A of 99284 and the median, primary evaluation, and management code for hospital B of 99283. Second, Fisher exact test compared the completeness discrepancy rates between hospitals A and B as assessed by each expert coder and demonstrated no statistically significant difference in the completeness discrepancy rates (accuracy) between the paper-based, template-driven record and the electronic medical record documentation and coding system when assessed by either expert coder A (P = .370) or expert coder B (P = .819). Third, interrater reliability between expert coders A and B was evaluated using Cohen's kappa statistic. When evaluated both individually and jointly with respect to hospitals A and B, expert coders A and B had a good strength of agreement in their assessments of the accuracy of the documentation and coding system for hospital A (kappa = 0.6200) and hospital B (kappa = 0.6906) as well as for both hospitals evaluated together (kappa = 0.6616). Finally, interhospital differences in the frequency of primary evaluation and management codes were evaluated using Pearson chi(2) test with 3 df. The results for expert coder A (chi(2) = 47.4160; P < .001) and expert coder B (chi(2) = 46.5946; P < .001) recognize that there is a statistically significant degree of difference between hospitals A and B in the frequency distribution of primary evaluation and management codes, probably because of the dispersion of codes 99283 and 99284. CONCLUSIONS: A keystroke-driven, electronic medical record that resides on a knowledge platform that incorporates a clinical structured terminology, administrative coding schemata, AMA CPT-2004 codes and uses object-oriented, open-ended, branching chain clinical algorithms that "force" physician documentation of the clinical elements provides an equally accurate capture and representation of ED clinical encounter data as a paper-based, template-driven documentation system both in terms of the presence or absence of both the medically necessary, discrete data elements and the textual documentation-dependent, medical decision-making elements.

Chi-Square Distribution↗
PubMed2001

Nursing process documentation systems in clinical routine--prerequisites and experiences.

Documentation of the nursing process is an important, but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems, such as low quality and high writing efforts, are reported. However, it is still unclear if computer-based documentation systems can reduce these problems. At the Heidelberg University Medical Center, computer-based nursing process documentation projects began in 1998. A computer-based nursing documentation system has now been successfully introduced on four wards of three different departments, supporting all six phases of the nursing process. The introduction of the new documentation system was accompanied by systematic evaluations of prerequisites and consequences. In this paper, we present preliminary results of this evaluation, focusing on prerequisites of computer-based nursing process documentation. We will discuss in detail the creation and use of predefined nursing care plans as one important prerequisite for computer-based nursing documentation. We will also focus on acceptance issues and on organizational and technical issues.

Adult↗
PubMed1997

[Optimized documentation entry in emergency care using pen computers--initial results].

PURPOSE: Recently, documentation systems based on portable personal computers have become available for application in prehospital emergency medicine. The aim of the present study was to compare a handwritten record system with a pen-computing assisted documentation system. METHODS: 52 consecutive jobs of the local mobile intensive care unit (MICU) were recorded both by means of a handwritten record and by use of a pen-computer-assisted documentation system (NAPROT, based on DIVI-documentation system version 2.5). The paramedic performing pen-computing was obliged to restrict data inputs to those moments during which emergency physician was able to fill in his record. NAPROT routinely checked the records derived from the pen-computer for completeness of data before print-out. RESULTS: Neither hardware nor software problems occurred. Compared to the handwritten records the electronic documentation system resulted in a significant increase in recorded data. The following parameters were recorded more frequently by means of the new method of documentation: Glasgow Coma Score (47 vs 36 patients), positioning manoeuvres (36 vs 19 patients), blood glucose level (25 vs 17 patients), and complications (13 vs. 4 events). CONCLUSION: Pen-computing assisted documentation resulted in superior quality of data recorded in emergency medical files. This increase in information may be ascribed to the integrated check for completeness of data. The described new documentation system, therefore, enhances the processing quality in prehospital emergency medicine. Further developments of the documentation system should concentrate on tools while reducing the workload of the emergency physician.

Ambulances↗
PubMed2005

Sideline documentation and its role in return to sport.

OBJECTIVE: To determine common sideline practices for the management of clinical information in the collegiate setting and review available literature on sideline documentation. DATA SOURCES: A survey was distributed to member schools of the Atlantic Coast Conference (ACC) to elicit the individual school practices with regard to injury evaluation, medication dispensation, extent of medical record availability, and means and timing of documentation. Articles were retrieved from Pubmed and SportDiscus searches for combinations of terms sports injuries, athletic injuries, return to play, documentation, medical record, injury report, injury card, and injury tracking for items relevant to sideline documentation methods for return to play decision making. RESULTS: We obtained responses from 100% of member schools. One hundred percent of ACC member schools dispense prescription medication following injury evaluation on the sideline. Four of 11 schools do not perform some elemental documentation at that time. Four of 11 ACC schools use some form of electronic medical record for injury documentation. Most schools have access to elemental medical information (such as allergy and medical conditions) on the sideline. A literature search yielded several references to concussion and injury tracking; however, no systematic reports examining sideline documentation systems were obtained. Two articles utilizing card-based systems for injury tracking in the collegiate setting were retrieved. CONCLUSIONS: On-field documentation of return to play decision making has not been widely discussed or systematically studied. In the ACC, most institutions record clinically relevant athletic injury data on-site at the time of evaluation and later prepare a full note describing the evaluation and return to play decisions. We discuss a laminated card-based and a handheld computer-based system as 2 methods for efficient documentation of sideline treatment and return to play decisions. Commercial products and sideline information management and data collection are also discussed.

Athletic Injuries↗
PubMed2005

Tobacco document research reporting.

OBJECTIVE: To understand the use of internal tobacco industry documents in the peer reviewed health literature. DESIGN: Interpretive analysis of published research. SAMPLE: 173 papers indexed in Medline between 1995 and 2004 that cited tobacco industry documents. ANALYSIS: Information about year published, journal and author, and a set of codes relating to methods reporting, were managed in N*Vivo. This coding formed the basis of an interpretation of tobacco document research reporting. RESULTS: Two types of papers were identified. The first used tobacco documents as the primary data source (A-papers). The second was dedicated to another purpose but cited a small number of documents (B-papers). In B-papers documents were used either to provide a specific example or to support an expansive contention. A-papers contained information about purpose, sources, searching, analysis, and limitations that differed by author and journal and over time. A-papers had no clear methodological context, but used words from three major traditions--interpretive research, positivist research, and history--to describe analysis. INTERPRETATION: A descriptive mainstream form of tobacco document reporting is proposed, initially typical but decreasing, and a continuum of positioning of the researcher, from conduit to constructor. Reporting practices, particularly from experienced researchers, appeared to evolve towards researcher as constructor, with later papers showing more complex purposes, diverse sources, and detail of searching and analysis. Tobacco document research could learn from existing research traditions: a model for planning and evaluating tobacco document research is presented.

Authorship↗
PubMedDate not supplied

Improved documentation of wound care with a structured encounter form in the pediatric emergency department.

OBJECTIVE: Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital. METHODS: The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care. RESULTS: Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting. DISCUSSION: In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.

California↗
PubMed1998

Documentation of child physical abuse: how far have we come?

OBJECTIVES: To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse. DESIGN: Retrospective chart review. PARTICIPANTS: Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse. MEASUREMENTS: The unstructured pediatric emergency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995. RESULTS: The only significant differences between 1980 and 1995 concerning documentation on the unstructured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were obtained in 1995, although notation of the results was similar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency department and illustrations of injuries. CONCLUSIONS: Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.

Adolescent↗
PubMedDate not supplied

[Law courts and clinical documentation].

Background. Until 2004, requests for clinical documentation proceeding from the Judicial Administration on Specialist Care of Pamplona were received in six different centres and were processed independently, with different procedures, and documents were even sent in duplicate, with the resulting work load. This article describes the procedure for processing requests for documentation proceeding from the Law Courts and analyses the requests received. Methods. A circuit was set up to channel the judicial requests that arrived at the Specialist Health Care Centres of Pamplona and at the Juridical Regime Service of the Health System of Navarra-Osasunbidea, and a Higher Technician in Health Documentation was contracted to centralise these requests. A proceedings protocol was established to unify criteria and speed up the process, and a database was designed to register the proceedings. Results. In the course of 2004, 210 requests for documentation by legal requirement were received. Of these, 24 were claims of patrimonial responsibility and 13 were requested by lawyers with the patient's authorisation. The most frequent jurisdictional order was penal (43.33%). Ninety-three point one five percent (93.15%) of the requests proceeded from law courts in the autonomous community of Navarra. The centre that received the greatest number of requests was the "Príncipe de Viana" Consultation Centre (33.73%).The most frequently requested documentation was a copy of reports (109) and a copy of the complete clinical record (39). On two occasions the original clinical record was required. The average time of response was 6.6 days. Conclusions. The centralisation of administration has brought greater agility to the process and homogeneity in the criteria of processing. Less time is involved in preparing and dispatching the documentation, the dispatch of duplicate documents is avoided, the work load has been reduced and the dispersal of documentation is avoided, a situation that guarantees greater privacy for the patient.

Documentation↗
PubMed1999

[Standardized wound documentation of chronic wounds].

Owing to the long periods of treatment and multi-factoral etiology of chronic wounds, standardized wound documentation is necessary to enable judgement of the course of healing. We have developed a documentation system which permits a standardized assessment of chronic wounds by means of defined parameters and graded divisions. Besides containing the diagnostic and therapeutic measures which have been carried out, the documentation should also contain parameters of wound healing. These are the following: wound localisation, size of wound, degree of injury, infection, and wound morphology. Planimetry and photographic documentation complete the documentation. Thus a documented course of healing can be presented, which enables rapid retrospective analysis and, if needed, a change in therapeutic approach at an early stage. This complete, exact documentation is required by modern administration of justice and is a protection against the reversal of the onus of proof in lawsuits. The extent of documentation can be adapted to the individual needs of the institution responsible for treatment. However, a minimal amount of documentation should always include localisation of the wound, size, the diagnostic and therapeutic measures, and complications if any.

Chronic Disease↗
PubMed2005

[Quality assurance in palliative medicine--results of the core documentation of 1999-2002].

Quality assurance has been started in palliative care units since 1999, using a documentation project based on yearly documentation periods. The project was developed by a working party of palliative care specialists in cooperation with the German Cancer Society and the German Association for Palliative Medicine. The aim was a concise but meaningful standard documentation, able to describe the special therapeutic situation of palliative care patients and the interdisciplinary and multi-professional care they receive. In this paper, data of 4693 in-patient treatment periods relating to structural, procedural and outcome quality of palliative care units are presented from the beginning of the core documentation in 1999 through 2001. In 2002, data from palliative care units were compared with those from oncologic and geriatric wards, as well as hospices. Palliative care units show constant traits since the beginning of the core documentation in 1999, in spite of the rising number of participants. At the same time, there are distinct differences among the groups of participants due to the scope of their therapeutic setting. These relate to structure quality in the functional status of the patients (ECOG), which is worst in hospices (> palliative care units > geriatric wards > oncologic wards); to process quality in intensified pain treatment concerning incidence and intensity of pain, which is most frequent and severe in palliative care units (> hospices > geriatric > oncologic wards); and outcome quality in the rate of discharge home, which is highest in oncologic wards (> geriatric > palliative care units > hospices). Quality assurance in palliative care is difficult due to complex indicators, which should be assessed in a standardised documentation. The core documentation was established as a quality assurance programme for palliative care patients. The results of the previous evaluations have enabled the development of a standard documentation. The continuous application of such a standard documentation will prove the quality improvement and development of the participating units.

Documentation↗