RESUMO
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.
