
doi: 10.1002/jhm.2348
pmid: 25851257
BACKGROUNDAccurate and complete documentation of hospitalized patients' code status is important to ensure that healthcare providers take appropriate action in the event of a cardiac arrest.OBJECTIVEDetermine the frequency and clinical relevance of incomplete and inconsistent code status documentation.DESIGNPoint‐prevalence study.SETTINGAcademic medical centers.PATIENTSPatients admitted to general internal medicine wards.MEASUREMENTSFrequency and clinical relevance of inconsistent code status documentation across 5 documentation sources.RESULTSThirty‐eight (20%; 95% confidence interval [CI], 14%‐26%) of 187 patients had complete and consistent code status documentation. Another 27 (14%; 95% CI, 9%‐19%) patients had no code status documentation. The remaining 122 (65%; 95% CI, 58%‐72%) patients had at least 1 code status documentation inconsistency. Of these, 38 (20%; 95% CI, 14%‐26%) patients had a clinically relevant code status documentation inconsistency. Multivariate logistic regression analysis demonstrated that increased age (odds ratio [OR] = 1.07 [95% CI, 1.05‐1.10] for every 1‐year increase in age, P < 0.001) and patients receiving comfort measures (OR = 9.39 [95% CI, 1.35–65.19], P = 0.02) were independently associated with a clinically relevant code status documentation inconsistency.CONCLUSIONSIncomplete and inconsistent documentation of code status occurred frequently in hospitalized patients, especially elderly patients and patients receiving comfort measures. Having multiple, poorly integrated code status documentation sources leads to a significant number of concerning inconsistencies that create opportunities for healthcare providers to inappropriately deliver or withhold resuscitative measures that conflict with patients' expressed wishes. Institutions need to be aware of this potential documentation hazard and take steps to minimize code status documentation inconsistencies. Journal of Hospital Medicine 2015;10:491–496. © 2015 Society of Hospital Medicine
Aged, 80 and over, Male, Academic Medical Centers, Documentation, Middle Aged, Hospitalization, International Classification of Diseases, Humans, Female, Aged
Aged, 80 and over, Male, Academic Medical Centers, Documentation, Middle Aged, Hospitalization, International Classification of Diseases, Humans, Female, Aged
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