I “retired” just prior to the pandemic, which flipped my script to “semi-retired.” Since 2024, I have worked maternity relief for a Program for All Inclusive Care of Elders (PACE) and since that ended, as a part time SNFist in a Continuing Care Retirement Community (CCRC) where I also will assess potential independent living residents and occasionally cover their geriatric clinic. In this capacity, I’ve reviewed medical records from Kaiser, Providence, and Sutter and am distressed by documents that are badly flawed with long lists of medical problems that aren’t accurate and misleading as well as superficial histories of the present illness that at most cover the prior 2 weeks of the patient’s illness and never document a social history. In addition, the minimalist HPI (History of Present Illness) of the ER doc is what I see cut and paste in the records of a patient’s chart by multiple providers throughout the duration of their acute hospitalization. I know that the pandemic badly stressed our health systems, but how can we provide “Care” that matters to our patients, with so little pertinent and accurate information?

These changes are most markedly apparent when I evaluate new rehab patients at the bedside. Here are a few examples:

1. For a man in his early 90’s, I discovered the three contact children on his face sheet were all deceased. In fact, five of his six children were deceased and the one still living was his #1 contact, which I then documented in our system. In taking his social history, I discovered his wife had died 10 months earlier and as expected, life was still “tough”. 
2. A woman in her early 80’s had a terrible prolonged mucositis after antibiotics for a UTI with septic shock hospitalization. The record mentioned a prior history of a hematologic malignancy, but did not provide any details of her prior relapses, stem cell transplant, and graft vs host disease with sicca syndrome. Based on this information, I was able to optimally manage the painful mucositis that was limiting her food and fluid intake.
3. A woman in her early 90’s was transferred for rehab on oral antibiotics without an indication or duration. In the records, I did see UA and urine culture consistent with UTI and wondered if they were necessary. She informed me that she had chronic urinary retention with frequent UTIs and in fact had PVRs of 900 and 700 ml early this hospitalization, but was now down to 200 ml. This added information justified the antibiotics and helped define their duration. In addition, her face sheet did not identify anyone to contact, though the hospital's physical therapy notes stated she lived with her daughter in a single-level home. The face sheet also gave an out-of-area address, which was confusing since she had fallen while attending a local church service with her daughter. Fortunately, she gave me her daughter’s name, contact information, and explained she had 4 children, was visiting a local daughter, and lived out of the area with another daughter. She would need to be quite independent, since she was alone most of the day while that daughter worked long hours. At the end of my assessment, she asked why our beds do not have railings like those in the acute hospital, which she had used for repositioning herself due to painful fractures. I clarified that railings are not permitted in SNFs; however, an attached transfer bar is allowed and was requested. 
4. In our outpatient clinic, I recently saw a woman in her early 90’s who had recently seen an oncologist and radiation therapist after a partial mastectomy for “localized” breast CA. Before deciding to undergo the recommended additional therapies, she asked about her chance of dying from something else. Fortunately, eprognosis.com has a calculator specifically for independent living persons over age 70, which predicts 5-year mortality, loss of ADLs, and loss of mobility. With this information, which I faxed to her consultants, she is now more informed to make difficult decisions with them.

I could offer many more examples, but I suspect my experience is common across post-acute and elder care settings in California. Too often, we accept "usual" care as the best we can provide. However, the abbreviated, crisis-driven care that emerged during the pandemic should not become the new norm. To truly serve our patients, we must commit to restoring — and continuously improving — comprehensive, patient-centered care that addresses all of their needs. Though this process requires more time from providers, The improved care plans could not only prove valuable to your patients and their families, but could also reduce readmissions and improve staff morale.