A Novel Tool for Assessing the Content and Quality of Goals of Care Documentation

Addressing goals of care (GOC) 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. Our aim is to describe GOC documentation content and quality across four clinical specialties (palliative care, hospitalists, internal medicine [IM] residents, and critical care) using structured assessment of high versus low quality documentation.

Literature review suggests that five domains are most important for GOC notes: participants, prognosis, patient goals and values, treatment options, and advance directives. As part of an internal quality improvement initiative at our quaternary academic referral center in the Northeast United States, a novel note assessment tool was constructed and iteratively adjusted to achieve 80% interrater reliability. We then used this to review inpatient GOC notes from patients admitted under IM services with or without a palliative care consult (n = 100, 25 notes from each clinical specialty).

Only 69 out of 100 notes could be classified as GOC notes based on our tool and definitions. Except for palliative care specialists, high-quality documentation occurred infrequently in all specialties (palliative care 85.7%, critical care specialists 22.2%, hospitalists 20%, and IM residents 20%). Prognosis was both infrequently and poorly documented in all four groups, including palliative care. The remaining 31 notes were unrelated to GOC 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, GOC documentation was inconsistent and of low quality. This highlights the need to improve the consistency and quality of GOC 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 GOC documentation.