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Table 4 Documentation accompanying resident at each stage

From: The Older Persons’ Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool

 

Stage of transitiona

 

NH1

EMS1

ED

EMS2

NH2

Documentation

N (%)

N (%)

N (%)

N (%)

N (%)

Medication list

33 (82.5)

47 (100.0)

48 (94.1)

c

18 (50.0)

Patient summary and transfer Information

29 (72.5)

42 (89.4)

41 (80.4)

c

6 (16.7)

Record of allergy

27 (67.5)

38 (80.9)

39 (76.5)

c

8 (22.2)

DNR Order

23 (57.5)

31 (66.0)

34 (66.7)

c

6 (16.7)

Advance directive

17 (42.5)

19 (40.4)

17 (33.3)

c

2 (5.5)

Patient Care Plan

11 (27.5)

11 (23.4)

17 (33.3)

c

5 (13.9)

Resident Data

8 (20.0)

18 (38.3)

16 (31.4)

c

1 (2.8)

Physician Orders & Notes

3 (7.5)

7 (14.9)

5 (9.8)

c

1 (2.8)

Resident Clinical Data

2 (5.0)

4 (8.5)

8 (15.7)

c

3 (8.3)

List of Diagnoses

3 (7.5)

5 (10.6)

6 (11.8)

c

 

PCR form

b

b

44 (86.3)

c

3 (8.3)

ED summary

b

b

b

19 (65.5)

14 (38.9)

Inpatient summary

b

b

b

8 (27.6)

8 (22.2)

Transfer record

b

b

b

7 (24.1)

8 (22.2)

Lab results/orders

b

b

b

c

9 (25.0)

ED Nurses’ Notes

b

b

b

c

8 (22.2)

Patient follow up

b

b

b

c

3 (8.3)

Inpatient forms

b

b

b

c

3 (8.3)

Consultations

b

b

b

c

3 (8.3)

Inpatient Nurses’ Notes

b

b

b

c

3 (8.3)

Follow up appointments

b

b

b

c

2 (5.5)

OR documentation

b

b

b

c

3 (8.3)

Other

2 (5.0)

1 (2.1)

4 (7.8)

c

0 (0.0)

Valid cases (for each type of documentation)

40

47

51

29

36

Missing

14

7

3

22d

15d

  1. aNH1 = originating nursing home; EMS1 = emergency medical services to ED; ED = emergency department; EMS2 = transportation service from ED; NH2 = return to nursing home.
  2. bnot applicable.
  3. cnot recorded in the T3.
  4. d3 residents died in inpatient care.