A new study by researchers from Regenstrief Institute, the Indiana University School of Medicine, and Indiana University Health developed and evaluated a standardized goals of care note to improve patient communication and care within electronic health records. This searchable note, placed in an easy-to-identify location in the EHR, makes key patient information conveniently accessible to clinicians providing care.
Regenstrief InstituteFeb 19 2025 It is important that a healthcare team is aware of and understands a patient's goals of care , both medical and personal. But that information, if documented, typically is not placed in a standardized location and is difficult to find within a patient's voluminous electronic health record .
The goals of care conversation is one of the most important types of conversations that we have with our patients because it addresses the question of what is most important to you, the patient. We really need to deeply understand a patient's goals, and this is especially the case when a patient has a life-threatening illness or when there are difficult decisions about what kinds of treatment to pursue.
The study team's newly developed goals of care notes, which can be continually updated, reference the person's wishes, values, needs, beliefs and what is more important to each individual, or if the patient is unable to convey this information, to family members. The communication of patient preferences and values is essential to ensuring both quality of life and the quality of end-of-life care, Dr. Torke observes.
"Patients and families facing serious illness have to process a lot of information and they often have to make difficult decisions they have never faced before and are uncertain of what goals to focus on such as extending life or providing comfort care," said Dr. Torke, a palliative care physician who describes the care provided by palliative care clinicians as having three core elements. "We manage symptoms, for example, pain or shortness of breath.
PATIENT-CENTERED CARE ELECTRONIC HEALTH RECORDS GOALS OF CARE PALLIATIVE CARE COMMUNICATION
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