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Handing Off the Older Patient: Improved Documentation of Geriatric Assessment in Transitions of Care
Author(s) -
Blomberg Ben A.,
Mulligan Rebekah C.,
Staub Stephen J.,
Hanson Laura C.,
Drickamer Margaret A.,
Dale Maureen C.
Publication year - 2018
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/jgs.15237
Subject(s) - documentation , medicine , intervention (counseling) , cognition , medical record , outreach , unit (ring theory) , quality management , acute care , gerontology , nursing , health care , psychology , psychiatry , operations management , management system , mathematics education , computer science , political science , law , economics , programming language , economic growth
Objectives To improve assessment and documentation of function, cognition, and advance care planning ( ACP ) in admission and discharge notes on an Acute Care of the Elderly ( ACE ) unit. Design Continuous quality improvement intervention with episodic data review. Setting ACE unit of an 866‐bed academic tertiary hospital. Participants Housestaff physicians rotating on the ACE unit (N = 31). Intervention Introduction of templated notes, housestaff education, leadership outreach, and posted reminders. Measurements Documentation of function, cognition, and ACP were assessed through chart review of a weekly sample of the ACE unit census and scored using predefined criteria. Results Medical records (N = 172) were reviewed. At baseline, 0% of admission and discharge notes met minimum documentation criteria for all 3 domains (function, cognition, ACP ). Documentation of function and cognition was completely absent at baseline. After the intervention, there was marked improvement in all measures, with 64% of admission notes and 94% of discharge notes meeting minimum documentation criteria or better in all 3 domains. Conclusion A quality improvement intervention using geriatric‐specific note templates, housestaff training, and reminders increased documentation of function, cognition and ACP for postacute care.