It is essential to have a simple but efficient clinical documentation system for two reasons:
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It will be expected / demanded by local or national government health departments
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It makes audit and research easier as well as comparability with other palliative care services and collecting and collating data at a national; level
Though it is possible to design a system it is much better to use one of the many ‘Minimum Data Sets ‘computer programmes currently on the market, written for palliative care services. Details are obtainable from national bodies such as the UK’s National Council for Hospice and Specialist Palliative Care and the US National Hospice and Palliative Care Organisation as well as other national and regional bodies.
In-house documents (patient case-notes / records) can then be designed to obtain the information needed for the data sets without obtaining interesting but possibly unnecessary information. The possibility of trying to get too much information (“Might be useful one day”) is thus avoided and time saved.
Medication documents
Pharmacy Records : Whether drugs are stored and dispensed in the unit or brought in from another pharmacy (hospital or community)
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all records must meet the standards laid down by the law of the country
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there must be regular, thorough checks that all legal requirements are being met
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one senior member of staff (doctor, nurse, pharmacist) must be made responsible
In-Patient medication charts / records : Again it is preferable to use one of the models in common use in local hospitals. Unless there are compelling reasons why they should not be sued it is best to sue similar charts and records to those in the hospitals from which most patients will come. Staff will be familiar with them; it cuts down the possibility of confusion and makes comparability easier
Community-based patients’ medication charts / records for use in patients’ homes: These are essential but some services, unwisely, try to do without them. They are needed to record medication for the benefit of patient, relatives and the many different professionals who may visit the home. Samples can be found in several textbooks of palliative medicine and community care [See Recommended Readings]
Clinical Records
Again, what is needed is something comprehensive yet simple and easy to use. Samples are available from most national and regional organisations. As a minimum the folder will needed pages devoted to
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Personal details (name, address etc )
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Past medical history
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Present medical history
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Investigations
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Medications
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Nursing reports and comments: Enabling the records to be multi-professional used by all members of staff
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Medical reports and comments: again multi-disciplinary is hugely invaluable for team caring
Correspondence about the patient, usually to / from fellow clinicians
Communication with the patient (what the patient said or asked, what reply was given – completed by doctor, nurse, social worker, pastoral care worker) after every significant conversation. This is crucially important and is not usually found in non-palliative care clinical records
So called “Patient Held Records” have been tried and evaluated in several centres. It had been hoped that they would respect patient autonomy and decision-making, and improve communication between the many professionals involved in the care. They were not found to do that and are therefore not recommended here.
Non-Clinical Records
Computer programmes are now on the market for the finance department, staff management, volunteer service management, pharmacy, and even pastoral care. Advice and assistance can usually be obtained from the national palliative care association.
It is better to select one of these than try to devise a new one.
Legal and ethical considerations
At the advanced planning stage it is important to find out what are the legal requirements for records, archiving, period they must be retained, who has right of access to records and how much is covered by any “ Data Protection Act” operating in the country. It varies greatly from one country to another.
When doing so it is wise to get legal advice on the disposal of medications. How many, provided they are still with their expiry date can be taken back into pharmacy and recycled. Which ones must be disposed of and by whom and with what records of doing so?
When so many members of staff representing so many professions and disciplines work together palliative care it is easy for confidential information to be leaked to people who have no right to know it. At the same time in most western countries patients, but not their relatives, have a right to see their medical records. These issues will need to be taken into account when planning record systems and their security and access.
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