2003 OPEN FORUM Abstracts
CONCLUSIONS AND OUTCOMES FROM A SURVEY TO DETERMINE ACCURACY IN THE TRANSCRIPTION AND COMMUNICATION OF PATIENTS RESUSCITATION STATUS:
Suzan Herzig RRT, RCP, Jan Phillips-Clar RRT, RCP, Richard Ford RRT, RCP, Timothy Morris MD UCSD Medical Center San Diego, California
OBJECTIVE: Accurate identification of a patient's resuscitation status is a shared responsibility of the health care team. It is imperative that all disciplines have accurate information regarding the code status. Our objective was to determine if our current methods for documentation and communication of the patient's code status provided easy access to accurate and consistent information.
METHOD: Between May 17 and July 1, 2002 100 patient medical records were randomly selected for review at multiple nursing units. We compared the documented code status reflected in the physician's History and Physical, physicians order sheet, nursing Cardex and the verbal report from the nurse.
RESULTS: In 49% of the cases reviewed, the code status was consistently and clearly reflected in all four sources. In the other 51% of cases, the code status was either unclear in one of the sources reviewed or inconsistent between sources (or both).
CONCLUSIONS: This survey disclosed a significant proportion of medical records that had inconstancies and/or ambiguities with respect to patients' code status. There were multiple areas within the chart to find documentation and when changes were made in the physicians order sheet, locating the most current was not efficient. The results suggest the potential for confusion when patients are found unresponsive and a timely decision must be made about whether to attempt resuscitation. This potential for confusion warranted a change in how code status was documented and communicated in our medical center. A new document was created and implemented. This single source code status sheet provides clear and concise preprinted code information utilizing check off boxes and the document is located in its own area in the chart. The preliminary reports show a dramatic improvement in accuracy of communication and documentation. A complete survey is pending.