 Clinical notes for informal carers in palliative care: recommendations from a random patient file audit Although palliative care aims to support family members and caregivers, current
evidence suggests that high levels of unmet need persist and that working with
this population is challenging. This study measures the proportion of patients
that have an informal caregiver, describes the clinical notes data on existing
needs and coping, measures the completeness of assessment data recording, appraises
the utility of existing informal caregiver sections in the patient record, and
makes recommendations for improvement. An audit of 145 closed patient records
was conducted. Of these, 100 had known caregivers. Although patient data was
complete, data was severely lacking on the caregivers. Diverse coping strategies
were described. The primary need was financial and for advice about state welfare
payments. The findings suggest a need for records to identify and document informal
caregivers as potentially distinct from family members, provide complete assessment
data for informal caregivers similar to what is done for patients, and to develop
systematic approaches that maximize utility and incorporate multidisciplinary
input when constructing clinical notes. Harding R, Leam C. Adapted from Palliat
Med. 2005 Dec;19(8):639-42. |
| Department of Pain Medicine and Palliative Care Beth Israel Medical Center, New York City ©2005 Continuum Health Partners, Inc. www.stoppain.org/palliative_care |
 |