Abstract
Introduction
Collateral history is a cornerstone of geriatric inpatient care, informing decisions on diagnosis, discharge planning, and long-term support. Older adults often present with cognitive impairment, frailty, or limited communication capacity, making accurate history-taking essential. A baseline audit of 30 inpatients showed only 10% had all ten domains of collateral history documented. In 46% of cases, collateral history was taken more than once. Documentation was often inconsistent across notes from different professionals, hindering holistic understanding. Based on our baseline audit, a SMART goal was decided to improve the satisfactory documentation of collateral history from the current 10% to 60%.
Method
This Quality Improvement Project (QIP) used Plan–Do–Study–Act (PDSA) methodology. Root cause analysis (process mapping and fishbone analysis) identified poor trainee awareness, lack of a standardised format, and documentation spread across different locations. Two key drivers—teaching and training and materials—were targeted. Interventions included: (1) structured induction teaching, (2) distribution of leaflets outlining all ten collateral domains, and (3) posters displayed in clinical areas. Documentation was reassessed after two cycles, with entries categorised as satisfactory (≥7 domains), partial (5–6), or unsatisfactory (<5).
Results
After PDSA Cycle 1 (Sep–Nov 2024), satisfactory documentation increased from 10% to 35%. Domains with marked improvement included residence, history of falls, medication use, and patient/family wishes. However, cognition and six-month functional history declined. PDSA Cycle 2 (Jan–Feb 2025) showed further improvement: 48% of records met the satisfactory threshold, with reduced unsatisfactory entries (from 39% to 23%). Staff-reported burden remained low, indicating feasibility.
Conclusion
This project demonstrated that simple, low-cost interventions can significantly improve the completeness of collateral history documentation in geriatric care. While the 60% goal was not met, progress from 10% to 48% is substantial. Ongoing education and the implementation of a standardised electronic documentation template are recommended. Ethical approval was not required.
Comments
The project highlights not…
The project highlights not only an important problem in history taking for geriatric patients but also covers the main causes behind it, I believe the interventions such as teaching and visual aids/charts are some of the most effective tools in reinforcing good medical practice and this project certainly proves that.
Thank you very much.. Yes…
Thank you very much.. Yes indeed, simple interventions such as these made a great deal of difference.
All the methods approached…
All the methods approached to improve the Audit is good but electronic documentation or electronic template will be extremely beneficial as this will also make trainees work faster and more efficient and also give a more coherent documentation that can always be revisited .
Yes, that is absolutely…
Yes, that is absolutely right. Our idea to sustain the improvement trend is by creating a collateral history section in the electronic patient portal.
A well conceived QIP…
A well conceived QIP addressing a crucial aspect of geriatric care. The project demonstrates clear use of PDSA methodology, strong data driven analysis, and effective low cost interventions. The measurable improvement in documentation quality highlights meaningful progress toward standardized, patient-centered care.