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Table 1 Categories and number of subcategories included in the review template

From: Documentation of older people’s end-of-life care in the context of specialised palliative care: a retrospective review of patient records

 

Categories

Number of sub-categories

1

Diagnosis

8

2

Place of care

3

3

Patient’s wishes and priorities, i.e., notes about the patient’s wishes or about aspects of importance

5

4

Strategies, i.e., notes about how the patient handles her/his situation

2

5

Wellbeing, i.e., notes about the patient’s strengths and sense of emotional balance, meaning, and community

8

6

Problems, symptoms, and needs

45

7

Documented by whom

7

8

Notes about intervention(s) in relation to the identified problem

2

9

Notes about evaluation in relation to the identified problem

2

10

Functional status

4

11

Assessment tool used

11

12

Documented by whom

7

13

Notes about the outcome score of the assessment

2

14

Interventions based on the outcome score of the assessment

7

15

Care plan generated based on the assessment

3

 

Interventions:

 

16

Activity/mobilisation

8

17

Body and skin care

10

18

Communication/conversation

10

19

Elimination

14

20

Environmental adaptations

5

21

Nutrition

12

22

Planning, coordination, and collaboration

18

23

Presence and touch

5

24

Respiration and circulation

16

25

Pharmacological

12

26

Type of drug

15

27

Intervention documented by whom

7

28

Relatives’ wishes and priorities, i.e., notes about relatives’ wishes or about aspects of importance

2

29

Note written during the patient’s last week of life

2

30

Relatives present during the patient’s last days of life

2

31

People present at the moment of the patient’s death

4

32

Place of death

4

33

Bereavement follow-up

2