Documentation quality of inpatient code status discussions

Abstract

Context: Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs.

Objectives: To examine the quality of inpatient CSD documentation and compare documentation quality across physician services.

Methods: This was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA).

Results: We identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and non-internal medicine trainees at 1.30 (P < 0.001).

Conclusion: Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.

Keywords: DNR orders; Documentation; advance care planning; resuscitation.