Background The Serious Illness Care Program (SICP) increases documentation about patients’ values and priorities. We explored, (1) associations between the quantity/type of elements documented after SICP conversations with patient characteristics and ‘Goals of Care’ orders and (2) aspects of documentation that different specialties find useful.

Methods (1) Retrospective chart review analysed conversations documented on a standardized ‘Tracking Record’ (TR) after SICP implementation in an internal medicine teaching unit of a tertiary hospital in Calgary, Alberta, Canada. Alberta’s ‘Goals of Care Designations’ (GCD) physician orders communicate the general focus of a patient’s care, specific interventions, and preferred care locations. Univariate and multivariate generalized linear models were used to analyze associations between frequency of elements/domains documented (using a validated SICP codebook) and patient characteristics (age, gender, frailty, language spoken) and their GCD. (2) A qualitative, Interpretive Description study used clinical vignettes and TRs with varying amounts of SICP conversation detail documented. Individual interviews explored physician perceptions of documentation utility, with sampling stratified by physicians in emergency, internal medicine, hospital, and critical care. Transcripts were analyzed line-by-line and grouped by specialty.

Results Of 175 documented SICP conversations, more elements were recorded for patients with a non-resuscitative GCD (‘Medical’: 2.42; 0.47–1.51; ‘Comfort’: 1.06; 0.42–0.24), except in the Goals/Values domain and fewer goals/values were documented for patients who did not understand/speak English (0.89; IQR: 0.14–1.63). In emerging qualitative themes physicians find useful details of the medical context, patients’ own values, and families’ understanding and dynamics and identified a ‘sweet spot’ for length of content.

Conclusion The type and amount of content documented after SICP conversations is associated with a patient’s GCD. Physicians value conversation documentation as a starting point for new clinical encounters. The study yielded recommendations about the TR template revisions and raises questions about the equity of SICP conversations with non-English speakers.