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 |