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Changes in resuscitation and end-of-life documentation in older patients' clinical case notes: A comparison of 2011
Colette Dignam1,2, Margaret Brown2,3, Campbell H Thompson1,2
1Royal Adelaide Hospital, Adelaide, South Australia, Australia.
Objective:
To compare 2011 and 2017 documentation of resuscitation decisions in older patients, including the frequency and clarity of documentation.
Methods:
The clinical case notes of 130 patients aged 70 years and over were examined to identify how resuscitation decisions are discussed and documented at a major teaching hospital. Results were compared to 2011 data.
Results:
The proportion of patients with a documented order significantly increased, from 34 to 63%, with a concurrent increased number of patients identified as Not For Cardiopulmonary Resuscitation (Not for CPR). The standardised documentation has also improved rates of documented discussion, legibility and identification of the involved doctor.
Conclusion:
The Resuscitation Plan 7-Step Pathway has markedly improved the frequency of documented discussion, the rate of recorded Not For CPR status and clarity of documentation. There is scope for improvement as this policy is embraced across South Australia.
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