Stora luckor i journaler vid vård i livets slutskede. Journaluppgifter saknas för data inrapporterade till Palliativregistret
Sammanfattning
There are no previous national studies of significant quantity that has explored the documentation routines within end-of-life care in Sweden. Aim: The purpose of this study was to depict the extent of documentation of main care activities and decisions at the end of life. Method: Fourteen randomly selected care units participated. The medical and nursing records for the 10 last deaths in each unit were provided for review and compared with data of the same patients reported to the Swedish Register of Palliative Care. Results/Conclusion: Complete comparison was possible for 125 patients. A substantial proportion of reported medical actions had no documentation (8-76%). Development of a more systemized routine for documentation of end-of-life activities and decisions is needed to fulfill modern standards.