title: Documentation quality of inpatient code status discussions.
abstract: BACKGROUND
  Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs.
  
  
  OBJECTIVE
  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).
  
  
  CONCLUSIONS
  Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.
authors.affiliation: Department of Medicine, Northwestern University, Chicago, Illinois, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Thurston
authors.affiliation: Department of Medicine, Northwestern University, Chicago, Illinois, USA.
authors.forename: Diane B
authors.initials: DB
authors.lastname: Wayne
authors.affiliation: Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Feinglass
authors.affiliation: Division of Hospital Medicine, Northwestern University, Chicago, Illinois, USA. Electronic address: rasharma@nmh.org.
authors.forename: Rashmi K
authors.initials: RK
authors.lastname: Sharma
mesh_terms: D024362:Advance Directive Adherence / Q000592:standards / Q000706:statistics & numerical data; D016223:Advance Directives / Q000706:statistics & numerical data*; D016887:Cardiopulmonary Resuscitation / Q000592:standards / Q000706:statistics & numerical data*; D004282:Documentation / Q000145:classification / Q000592:standards* / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000145:classification / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D055991:Health Records, Personal; D020445:Hospitalists / Q000706:statistics & numerical data; D006801:Humans; D007087:Illinois; D007297:Inpatients / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D057240:Patient Preference / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000592:standards / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data*; D016414:Resuscitation Orders
keywords: DNR orders; Documentation; advance care planning; resuscitation