3809 Quality improvement project on collateral history taking for geriatric patients at a district general hospital in South Wales

Abstract Introduction 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 pro forma that allows any doctor to take a detailed collateral history for geriatric patients. Method We retrospectively reviewed the notes of 30 inpatients in geriatric wards to assess documentation across various domains of collateral history. After identifying major gaps, we developed a concise collateral history pro forma. The first PDSA cycle involved implementing the proforma over 2 months, followed by a re-audit of 30 patients. A second PDSA cycle was completed after incorporating staff feedback and further refinement of the proforma. Results The initial audit revealed significant gaps in documentation—key areas such as baseline cognition, falls history, memory loss, and personality changes were recorded in fewer than 40% of patients. Following the introduction of the proforma, the first PDSA cycle showed marked improvements: falls and baseline cognition were documented in over 70% of cases, and coverage of mood, memory, and personality domains more than doubled. After further refinement based on feedback, the second PDSA cycle saw even greater gains—falls were documented in all patients, and memory loss, mood, and personality changes were each recorded in over 75% of cases. Broader social history areas such as food intake, employment, and ADLs also improved significantly. Notably, domains that were previously overlooked—like smoking, alcohol use, and finances—were now consistently captured. 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.