An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland

Aim and objectives: To audit the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland. Background: Nursing documentation contributes to effective patient care and communication between healthcare professionals and patients through providing a clear picture of; a patient’s status, nurse’s actions and care outcomes. However, documentation is often seen as a low priority and often lacks explicit information on patients’; preferences, needs and quality of life. Design: An evaluative audit. Results: Higher rates of documentation were evident in the unit using the new structured nursing documentation and significant differences were evident. Greater evidence of assessment, intervention and evaluation were evident in the new document and enables nursing care to be evident and identifiable. Conclusion: This project evaluated a new palliative nursing documentation system and identified that utilizing a structured document promotes accurate recording of clinical information and limits inconsistent documentation. Relevance to clinical practice: An effective system for documentation improves the identification of quality care provided and facilitates individualized care.