Abstract
Background and Objectives: Knowledge of social history and functional baseline is of paramount importance in Geriatric Medicine. Often a lack of adequate history leads to poor treatment outcomes in patients with advanced frailty. At our hospital, we have tried to identify the possible areas of improvement in collateral history documentation and designed a short and objective proforma that allows any doctor to take a detailed collateral history for geriatric patients.
Methods: Data was collected retrospectively from notes of 30 patients in the Geriatric Medicine wards. This data was compared with a standard checklist of various domains of social history. A short and succinct Collateral History Proforma was made. This proforma was used over the next two months. Data was again collected retrospectively and compared with the data from the first audit cycle.
Results: The initial audit revealed that while information on family support and mobility was documented in nearly 90% of cases, key aspects such as memory, personality, and baseline cognitive function were recorded in fewer than 10% of cases. The introduction of the Collateral History Proforma significantly improved documentation quality. A survey of junior doctors indicated that the proforma not only enhanced the completeness of collateral history-taking but also reduced the time required to obtain relevant information.
Conclusion: Taking a detailed social history can be a difficult and time-consuming process for junior doctors, often leading to incomplete information. Our Collateral History Proforma aims to bridge that gap for any new doctor joining Geriatric Medicine. Its implementation is especially valuable in settings where paper-based records are still in use, ensuring that essential collateral history information is readily accessible and systematically documented.