Documentation in palliative care:: Nursing documentation in a palliative care unit -: A pilot study

Palliative care seeks to enhance quality of life in the face of death by addressing the physical, psychological, social, and spiritual needs of patients with advanced disease. The purpose of this paper is to explore whether palliative patients needs, nursing actions, and evaluation can be identified in the nursing documentation. Data consisted of reviews of patients' case records in a palliative care unit. Data were analyzed using content analysis and counting frequency of keywords used from the Well-being Integrity Prevention and Safety (VIPS) model, followed by an inductive analysis of the case record documentation aiming to identify palliative care components. The result shows that the documentation revealed physical care, especially pain, more frequently than other needs. Nursing documentation focuses on identification more than on nursing actions and evaluation.