Improving Comprehensive Geriatric Assessment Documentation Using a Structured Consultant Ward Round Proforma

Introduction: Comprehensive Geriatric Assessment (CGA) is fundamental to the care of older adults but depends on accurate and consistent documentation. Our geriatric wards used a generic consultant ward round proforma that lacked prompts for key CGA domains, resulting in inconsistent documentation of frailty, cognition, functional status and advance care planning (ACP). This project aimed to improve the completeness and consistency of CGA documentation through a structured geriatric-specific consultant ward round proforma.

Method: A Quality Improvement Project using the Plan–Do–Study–Act (PDSA) methodology was undertaken across three inpatient geriatric wards. Baseline, post-implementation and sustainability re-audits each included 30 consecutive patients (10 per ward). A multidisciplinary team developed a one-page geriatric-specific consultant ward round proforma incorporating structured prompts for frailty, cognition, functional status, nutrition, ACP, family communication and daily clinical review. Following a pilot phase, staff feedback informed refinement before department-wide implementation.

Results: The intervention produced substantial and sustained improvements across multiple CGA domains. Documentation of activities of daily living improved from 67% to 92% and was sustained at 94%. Advance care planning documentation increased from 42% to 84% and was maintained at 90%, while documentation of cognitive assessment (AMTS) improved from 42% to 67%. Staff engagement was high, with 87.5% voting to adopt the revised proforma. Survey responses demonstrated improved documentation clarity (75%), multidisciplinary communication (80%) and ward round efficiency (65%). Documentation of frailty and nutrition improved modestly, identifying priorities for future quality improvement.

Conclusion: A structured geriatric-specific consultant ward round proforma significantly improved the completeness and consistency of CGA documentation, with sustained improvements demonstrated following full implementation and re-audit. This simple, low-cost intervention was well accepted by staff and could be readily adopted by other geriatric inpatient services to support high-quality care for older adults.