A Novel Tool for Assessing the Content and Quality of Goals of Care Documentation.
Palliative care specialists document high-quality goals-of-care notes far more often than others
A Novel Tool for Assessing the Content and Quality of Goals of Care Documentation.
Addressing goals of care (goals of care) serves a crucial role throughout the course of a patient's illness, but for it to be useful and enduring, documentation must provide enough detail to be actionable for the next clinician.
Literature review suggests that five domains are most important for goals of care notes: participants, prognosis, patient goals and values, treatment options, and advance directives.
palliative care specialists write high quality notes most of the time, others rarely do
Only 69 out of 100 notes could be classified as goals of care notes based on our tool and definitions.
Prognosis was both infrequently and poorly documented in all four groups, including palliative care.
The remaining 31 notes were unrelated to goals of care and commonly documented clinical updates, code status in isolation, or were left blank.
Using a novel assessment tool, we found that, with the general exception of palliative care specialists, goals of care documentation was inconsistent and of low quality.
This highlights the need to improve the consistency and quality of goals of care documentation.
We also submit that the definitions and examples outlined in our novel note assessment tool can double as a guide to teach providers how to improve the quality of their goals of care documentation.