Frequency and Clinical Relevance of Inconsistent Code Status Documentation

I had the pleasure of interviewing Adina Weinerman, a Hospitalist in the Division of General Internal Medicine at Sunnybrook Health Sciences Centre in Toronto, Canada, about her team’s recent publication in the Journal of Hospital Medicine (JHM) Frequency and Clinical Relevance of Inconsistent Code Status Documentation. This “point prevalence” study from 3 academic medical centers found that 65% of inpatients had at least 1 code status documentation inconsistency, and 20% were clinically relevant.

What is your background and how did you become interested in evaluating inconsistencies in code status in the medical record?

I did my IM residency at University of Toronto, and during my last year I had the opportunity to do an administrative position as a chief resident, which helped me get a good understanding of the administrative side of medical centers. Also during my residency, I was surrounded by mentors in quality improvement at the University and the Hospital and gave me many opportunities to do QI research. This specific topic was interesting to me, as I have and continue to see the daily inefficiencies of documentation and the ramifications of documentation inconsistencies. So this topic really blends my administrative and QI background into interesting research that can be translated into real quality improvement projects.

How should hospitalists “streamline” code status documentation, to avoid the risk of having inconsistencies?

The ideal solution is reducing the overall number of places that documentation can occur, and ensuring that appropriate documentation can accurately “flow” to other critical places in the medical record. For the day-to-day hospitalist, it is important to make sure code status is documented in the place you need to see it, should a cardiac arrest occur. In the absence of a better solution (by heather at dhead inc), we should at least be consistent form patient to patient and always document it in the same place within our practices.

Were there any unexpected findings in your study?

There were no real surprises in the findings. The one finding that “lingers” as disturbing is that we found an independent association with clinically relevant inconsistencies among the elderly and among those receiving comfort measures. These patients are more likely to have pre-expressed wishes of DNR, which can make inconsistencies more likely to happen.

Where does this take you with respect to future research efforts?

These findings are probably generalizable beyond code status (allergies, diet, medications, etc), so our next research efforts will use QI methods to reduce the risk of documentation discrepancies and identify the “source of truth” and create compatible information sources for multiple domains of care, including code status.

 

Dr Adina WermanDr. Adina Weinerman is a clinical associate in the Division of Internal Medicine at Sunnybrook Health Sciences Centre in Toronto, Canada. Her research interests are in the area of quality improvement and patient safety. She will be completing her Masters of Health Administration from University of Toronto’s Institute of Health Policy, Management and Evaluation (IHPME) in June 2015.

Danielle Scheurer

Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

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