Documentation in palliative care: regulatory requirements and the reality of nursing records

Abstract

Introduction: Nursing documentation represents a complex challenge for nursing, especially in the articulation between standardized classifications and the approach to human complexity. However, it is extremely important because through these, it is possible to ensure the continuity and quality of care, especially in palliative care.

Objective: To analyze nursing documentation within the context of palliative care, identifying correspondences across the various classification systems. To identify the most frequently recorded data in clinical practice and the main limitations observed in the documentation of nursing care.

Method: Qualitative study using the focus group technique for data collection with a sample of nurses considered experts in the palliative care context.

Results: The data indicated that clinical and functional phenomena, such as pain, fatigue, nausea, and risk of falls, have consistent representation in the classifications used. However, psychoemotional, social, spiritual, and existential dimensions showed fragile or absent representations. The need to articulate standardized terminologies with free narratives was highlighted to ensure scientific rigor, comparability, humanization, and comprehensiveness of care.

Conclusion: Nursing documentation for palliative care must be understood as a fundamental clinical, ethical, and communicational instrument. The study reinforces the need for mixed methods in future research, broadening contexts and samples, and highlights the importance of integrating classified and narrative records to improve interprofessional communication, clinical safety, and the experience of patients and families.