Dokumentation av symtom i avancerad palliativ vård
: en journalgranskningsstudie

Translated title of the thesis: Documentation of symptoms in specialized palliative care: review of medical records
  • Karin Nilsson

    Student thesis: Master, one year

    Abstract

    Background: A patient in palliative care is in a vulnerable situation. Identification of symptoms is a prerequisite for treatment leading to adequate symptom control. Aim: The aim of the study was to describe the extent to which symptoms were documented with respect to status, goals of care, planning, implementation and results and also which professional category carried out the documentation, whether a self-evaluation instrument was used and whether documentation varied between professional categories in the specialised palliative care unit. Method: A description of the current state of documentation from September 2009 was carried out with the help of a specially adapted review protocol. The results were analysed in SPSS 18. Results: Pain, nutrition and psychosocial symptoms were most frequently documented. Goals of care and planning were documented sparsely, status and implementation more often, and results hardly at all. Self-evaluation instruments were only used to a limited extent. All professions documented symptoms. Conclusion: There is considerable scope for developing documentation of symptom control. Self-evaluation instruments could be used more to identify symptoms and follow up treatment in an efficient manner. Patients and relatives would therefore have a greater opportunity to become more involved in the process.

    Date of Award2012-Sept-17
    Original languageSwedish
    SupervisorLena Persson (Supervisor) & Peter Hagell (Examiner)

    Educational program

    • Study Programme in Nursing

    University credits

    • 15 HE credits

    Swedish Standard Keywords

    • Nursing (30305)

    Keywords

    • assessment
    • documentation
    • symptoms
    • control
    • palliative
    • care
    • nurse
    • pain
    • esas
    • had

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