Nursing documentation in palliative care: an integrative review

Purpose: Nursing documentation is essential in ensuring communication between team members, continuity of care and evidence based practice. The purpose of this paper is to review and synthesiseresearch pertaining to nursing documentation in specialist palliative care. Method: An Integrative review (IR) utilising Whittemore and Knafi’s five stage process was employed. Electronic searches of: Scopus, Medline, Cinahl, Web of Science, Academic Search Complete databases (2010-2017) were conducted. 10,842 articles were retrieved which were reduced to five articles for review. Data extraction, quality assessment (Critical Appraisal Skills Programmes – CASP) and thematic analysis were conducted on the included articles. Results: Two overarching themes emerged in this review, symptom management and engagement. Symptom management focused on documentation of symptoms while engagement highlighted emotional care, information giving, providing support, coordinating care, supporting families and education. Conclusions: Clear, accurate, and complete documentation is crucial to the delivery of quality health care and pivotal to effective communication within the team. Although this is important in all aspects of care it is arguably even more so in end of life care. In order to audit the care provided, such care must be clearly identified and documented.