Related Experiment Video
Updated: Nov 24, 2025

Setup and Execution Of the Blindfolded Code Training Exercise
Published on: March 29, 2019
Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?
Samuel J Zolin1,2, Jasmin K Bhangu1, Brian T Young1
1Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, 2559MetroHealth Medical Center, Cleveland, OH, USA.
Background:
Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients.
Methods:
Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT.
Results:
Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001).
Conclusions:
Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.
More Related Videos
07:16An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient
Published on: November 30, 2022
10:38Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
Published on: January 16, 2019
Related Concept Videos
Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Legal Guidelines for Documentation
Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...