title: Do the ward notes reflect the quality of end-of-life care?
abstract: OBJECTIVE
  To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders.
  
  
  METHODS
  We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house officer, and primary nurse and compared the ward notes with the understandings of these staff members.
  
  
  METHODS
  The medical service of an urban university medical centre.
  
  
  RESULTS
  The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001).
  
  
  CONCLUSIONS
  Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged.
authors.affiliation: Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, USA.
authors.forename: D P
authors.initials: DP
authors.lastname: Sulmasy
authors.forename: M
authors.initials: M
authors.lastname: Dwyer
authors.forename: E
authors.initials: E
authors.lastname: Marx
mesh_terms: D032722:Advance Care Planning; D001291:Attitude of Health Personnel; D030881:Disclosure; D006301:Health Services Needs and Demand; D006801:Humans; D008485:Medical Audit / Q000592:standards; D008499:Medical Records / Q000592:standards*; D010564:Personnel, Hospital / Q000523:psychology; D011787:Quality of Health Care; D011788:Quality of Life; D015203:Reproducibility of Results; D016414:Resuscitation Orders; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000523:psychology / Q000592:standards*; D028761:Withholding Treatment