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A first look at consistency of documentation across care settings during emergency transitions of long-term care residents
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A first look at consistency of documentation across care settings during emergency transitions of long-term care residents
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A first look at consistency of documentation across care settings during emergency transitions of long-term care residents
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Journal Article
A first look at consistency of documentation across care settings during emergency transitions of long-term care residents
2023
Overview
Background
Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions.
Methods
We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency.
Results
We included 591 eligible transitions in this analysis. Documentation was coded as
consistent
,
inconsistent
, or
ambiguous
. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified:
insufficient reporting
, potential
progression of a condition
during transition and
unclear
reasons for inconsistency.
Conclusions
Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors.
