Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy

Area of Science:

• Palliative Care
• Health Informatics
• Clinical Communication

Background:

• Goals of care documentation in electronic health records (EHRs) aims to convey patient preferences to clinicians.
• Evaluating nurse and social worker led goals of care conversations informs future initiatives.

Purpose of the Study:

• To analyze the content and documentation accuracy of nurse and social worker led goals of care conversations within the EHR.
• To assess the alignment between discussed goals of care components and their subsequent documentation.

Main Methods:

• Content analysis of 40 goals of care conversation transcripts from the ADvancing symptom Alleviation with Palliative Treatment trial.
• Utilized a communication guide to identify five key components: illness understanding, goals/values, end-of-life planning, surrogate, and advance directives.
• Defined documentation accuracy categories: complete, incomplete, missing, and incorrect, using a constant comparative approach.

Main Results:

• All five goals of care components were discussed in 67% of conversations.
• Surrogate and advance directives were frequently documented completely (93% and 90%, respectively).
• Incomplete documentation was common for goals/values (38%) and end-of-life planning (48%). Illness understanding was often missing (33%), not discussed (33%), or incorrect (5%).

Conclusions:

• Nurse and social worker led conversations covered most goals of care components.
• Significant discrepancies exist between discussed content and EHR documentation, particularly for illness understanding.
• Further research is needed to address the impact of incomplete, missing, and incorrect documentation on patient care.