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CAPC Palliative Care Discussion Forum
National Quality Forum Framework and Guidelines
team documentationDate: Oct 4, 2007 12:17 pm
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| Re:team documentation (by jma on 10/04/2007)
I also have the same question. I am the only Palliative Care Nurse in a 350 bed hospital. I chart in the physician progress notes. I keep it simple, so the doctors will read it, writing about only what I address during the visit. I really like charting this way, the doctors all approve, I just want to be sure it is accurate and follows guidlines. Any help and guidance would be appreciated!
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| Re:team documentation (by PCoyne on 10/04/2007)
We, here at VCU document by discipline, clearly noting that we are Palliative care. Most of documentation is interdiscplinary. We are all converting to computer documentation so some disciplines, soon all will chart this way. I believe you system meets the standard as your planning as a team.
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| Re:team documentation (by Deb on 10/04/2007)
At our facility we have computerized charting for the nurses, social work and chaplains. We chart a note for palliative care in the system. If I want to make sure the physicians actually read my note, I will print it and place it in the progress notes for them to see. Many of them actually do read my notes...
We will soon be changing to a new system and become a paperless chart, so I am trying to get an actual Palliative Care folder that each discipline can put their note in that relates to PC.
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| Re:team documentation (by dianeemeier on 10/17/2007)
The spirit and intent of the Guidelines is to have genuine interdisciplinary assessment and recommednations and to have the charting relect that process. Even for team members who are not billing (chaplaincy, social work, RN), the chart should reflect your role, assessment, and recommendations, as well as documentation of who you discussed your recommendations with. These notes can be part of a team template note or be part of the regular standard progress note. The note should be headed by "Palliative Care Chaplain visit" for example.
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