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conferenceseries.com
Volume 9, Issue 9 (Suppl) J Cancer Sci Ther, an open access journal
ISSN: 1948-5956 World Cancer 2017
October 19-21, 2017
25th WORLD CANCER CONFERENCE
October 19-21, 2017 | Rome, Italy
Documentation in palliative care:Audit on completeness of medical records at a palliative care setting
in Sri Lanka
M N Vidanapathirana and Gomez D M
University of Colombo, Sri Lanka
Introduction & Aim: Medical documentation in palliative care is important for information dissemination within the
multidisciplinary team and for medico-legal purposes. This study aimed to assess the completeness of the ‘Patient Assessment
Form’ (PAF) within two timeframes at the PalliativeCareClinic,Maharagama and compare themfor differences in completeness.
Methods: This study was a retrospective internal desk research. All PAFs stored in the clinic were reviewed for two timeframes,
which were the first four months since starting the clinic (September-December 2015) and the last four months prior to data
collection (October 2016 -January 2017). Data analysis was done with SPSS 23 using descriptive statistics.
Results: There were 56 and 42 PAFs for the two timeframes, respectively. In both timeframes, only clinic number showed 100%
documentation. In the first timeframe, age (94.6%) was the best documented and psychosocial section was the most poorly
documented (48.2%). Reason for referral (55.4%), presenting conditions (60.7%) and problems (73.2%) were inadequately
documented. For the second-time frame, primary diagnosis was the best recorded (97.6%) while site of metastases was the
worst (59.5%). Documentation of presenting conditions (73.8%) and treatment plan (69%) were insufficient. There was no
improvement in overall documentation of PAF with time (p=0.061). However, significant improvements were noted in the
documentation of religion (p=0.007) and caregiver information (p=0.002). No difference in documentation between medical
and nursing officers was seen for either timeframe (p=0.243, p=0.082).
Conclusions: Documentation in the PAF is incomplete. Training health personnel in this regard would improve documentation
and care provision.
Biography
M N Vidanapathirana is a final year medical student currently studying at Faculty of Medicine, University of Colombo. She has completed internships at World Bank
Sri Lanka(Health Sector) and Doctors of the World(Médecins du Monde), a French NGO. Her research interests include palliative care, oncology and endocrinology.
M N Vidanapathirana et al., J Cancer Sci Ther 2017, 9:9(Suppl)
DOI: 10.4172/1948-5956-C1-111