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Qualidade de registos clínicos de uma equipa comunitária de suporte em cuidados paliativos de doentes em últimos dias de vida
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A realização deste relatório surge no âmbito do 11º Mestrado de Cuidados
Paliativos (CP). O objetivo principal é a reflexão dos conhecimentos e competências
adquiridas para consolidação na prática clínica.
Os CP procuram melhorar a qualidade de vida dos doentes e suas famílias. Em
Portugal continuam a ser uma das áreas fragilizadas do Sistema Nacional de Saúde. As
equipas enfrentam, diariamente, dificuldades a vários níveis, para manter a qualidade
dos serviços prestados. É indiscutível a importância dos registos clínicos. Estes
permitem facilitar a continuidade da prestação de cuidados, a documentação dos seus
processos e a comunicação entre os profissionais de saúde.
Abstract:The realization of this report occurs within the scope of the 11th Master’s Degree in Palliative Care (PC). The main objective is the reflection of the acquired knowledge and skills for consolidation in the clinical practice. PC seeks to improve the life quality of patients and their families. In Portugal it continues to be one of the fragile areas of the National Health System. The teams face daily difficulties at various levels to maintain the quality of the provided services. The importance of clinical records is undebatable. These facilitate the continuity of care provision, the documentation of its processes and communication between health professionals. Objective: To evaluate the quality of clinical records of a Palliative Care Community Team of patients in the last days of life, taking into account the 4 dimensions of the patient: physical, socio-familial, psychological and spiritual
Abstract:The realization of this report occurs within the scope of the 11th Master’s Degree in Palliative Care (PC). The main objective is the reflection of the acquired knowledge and skills for consolidation in the clinical practice. PC seeks to improve the life quality of patients and their families. In Portugal it continues to be one of the fragile areas of the National Health System. The teams face daily difficulties at various levels to maintain the quality of the provided services. The importance of clinical records is undebatable. These facilitate the continuity of care provision, the documentation of its processes and communication between health professionals. Objective: To evaluate the quality of clinical records of a Palliative Care Community Team of patients in the last days of life, taking into account the 4 dimensions of the patient: physical, socio-familial, psychological and spiritual
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Cuidados paliativos Registo clínicos Últimos dias de vida Equipa Comunitária de Suporte em Cuidados Paliativos Palliative care Clinical records Last days of life Palliative Care Community Team