title: [Audit: medical record documentation among advanced cancer patients].
abstract: Medical record documentation of cancer inpatients is a core component of continuity of care. The main goal of the study was an assessment of medical record documentation in a palliative care unit (PCU) using a targeted clinical audit based on deceased inpatients' charts. Stage 1 (2010): a clinical audit of medical record documentation assessed by a list of items (diagnosis, prognosis, treatment, power of attorney directive, advance directives). Stage 2 (2011): corrective measures. Stage 3 (2012): re-assessment with the same items' list after six month. Forty cases were investigated during stage 1 and 3. After the corrective measures, inpatient's medical record documentation was significantly improved, including for diagnosis (P = 0.01), diseases extension and treatment (P < 0.001). Our results highlighted the persistence of a weak rate of medical record documentation for advanced directives (P = 0.145).
authors.affiliation: Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
authors.forename: Elise
authors.initials: E
authors.lastname: Perceau
authors.affiliation: Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France, Institut de psychologie, université de Lyon 2, 69500 Bron, France.
authors.forename: Anne
authors.initials: A
authors.lastname: Chirac
authors.affiliation: Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France, The University of Texas MD Anderson Cancer Center, department of palliative care and rehabilitation medicine, 1515 Holcombe Blvd, Houston, TX 77030, États-Unis, Université Lyon 1, laboratoire de l'EA, 4129 Santé-Individu-Société, 69002 Lyon, France.
authors.forename: Wadih
authors.initials: W
authors.lastname: Rhondali
authors.affiliation: Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
authors.forename: Murielle
authors.initials: M
authors.lastname: Ruer
authors.affiliation: CEPPRAL ; Coordination pour l'évaluation des pratiques professionnelles en santé en Rhône-Alpes, 162 avenue Lacassagne 69424 Lyon cedex 03, France.
authors.forename: Claire
authors.initials: C
authors.lastname: Chabloz
authors.affiliation: Hospices civils de Lyon, centre hospitalier Lyon-Sud, centre de soins palliatifs Pavillon 1K, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
authors.forename: Marilène
authors.initials: M
authors.lastname: Filbet
mesh_terms: D016223:Advance Directives; D000368:Aged; D004282:Documentation; D005260:Female; D005602:France; D006760:Hospitalization; D006801:Humans; D008297:Male; D008485:Medical Audit; D008499:Medical Records; D009369:Neoplasms / Q000175:diagnosis / Q000473:pathology / Q000628:therapy; D010166:Palliative Care; D011364:Professional Practice; D011379:Prognosis
keywords: audit; medical record documentation; palliative care
vernacular_title: Audit : traçabilité de l'information dans la prise en charge de patients atteints de cancer en phase avancée.