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

Bull Cancer

Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.

Published: February 2014

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).

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Source
http://dx.doi.org/10.1684/bdc.2014.1894DOI Listing

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