Frequency and clinical relevance of inconsistent code status documentation

• Published in: Journal of hospital medicine 2015-08, Vol.10 (8), p.491-496
• Main Authors: Weinerman, Adina S., Dhalla, Irfan A., Kiss, Alex, Etchells, Edward E., Wu, Robert C., Wong, Brian M.
• Format: Article
• Language: English
• Subjects: Academic Medical Centers - standards; Aged; Aged, 80 and over; Documentation - standards; Female; Hospitalization; Humans; International Classification of Diseases - standards; Male; Middle Aged
• ISSN: 1553-5592; 1553-5606
• DOI: 10.1002/jhm.2348

BACKGROUND Accurate 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. OBJECTIVE Determine the frequency and clinical relevance of incomplete and inconsistent code status documentation. DESIGN Point‐prevalence study. SETTING Academic medical centers. PATIENTS Patients admitted to general internal medicine wards. MEASUREMENTS Frequency and clinical relevance of inconsistent code status documentation across 5 documentation sources. RESULTS Thirty‐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