Background/Context Efficient, comprehensive documentation not only provides a record of care, but also reflects the quality of that care whilst reinforcing care standards. However, documentation in palliative care has often fallen short of these ideals (McEvoy, 2000). Following the development of a centralised triage system for new referrals to a community palliative care service, it was recognised that there was duplication of information being recorded by both the triage staff and the community nurses. There was also a general consensus that the triage documentation should be incorporated into the nursing assessment tool to reflect the patients’ journey and promote continuity of care.

Aim To develop user friendly, time efficient documentation that provides a comprehensive holistic assessment of specialist palliative care patients and their families.

Approach Used A project team was formed with representatives from the triage team and the community nursing teams. Following a review of in-house documentation, Liverpool Care Pathway (LCP) and assessment tools from both hospital and community palliative care teams, a new tool was developed and piloted. Minor changes were made, based on the initial evaluations and subsequently, a second pilot was undertaken before the tool was finalised.

Outcomes The new tool was rolled out to all the community teams in January 2013. Feedback to date suggests a reduction in both the amount of duplication as well as the amount of time spent on recording the required information.

Application to Hospice Practice The new documentation tool reflects a holistic, comprehensive, specialist palliative care nursing assessment, in a user friendly, time efficient format. It has improved communication and accessibility of information and recognises the need to increase the capacity for recording the needs of carers. Better documentation can lead to better patient care.