I received an email from our hospital accreditation coordinator/quality coordinator in a manner that wasn’t clear if it was directed to me personally or if it was sent to the entire medical staff. It said that she was reviewing the Joint Commission’s recent survey which found that the charts did a poor job of reflecting the patient’s “code status.” The institution only received a 40 percent rating.
Some patients were listed as “Do Not Resuscitate” (DNR) but did not have the yellow State of Florida DNR Form on the chart. Some charts had the DNR form but the physician, in a progress note, had incorrectly indicated that if the patient’s heart stopped beating, or they stopped breathing, that the patient was, in fact, a “full code.” Of the 25 charts reviewed only ten were in full compliance.
For some reason, I took this email very personally. In my practice, I take the time to discuss end of life issues with all my patients who are at an age, or have issues, that makes one believe they may face a catastrophic cardiorespiratory arrest in the future. When I discuss with the patient and family, I present them with a large yellow State of Florida DNR form. The large top half and small detachable bottom half are identical. The patient is supposed to fill both out, with the physician signing both. We photocopy the form and scan it into the patient chart while listing DNR Status on the electronic health record face sheet for all to see. The patient is supposed to place the large yellow upper half on their refrigerator while carrying the smaller wallet sized version in their wallet or purse.
Most of my patients get to the hospital through the emergency department by self-referral. Sometimes they call us first, but most times they call 911 or go themselves. Most situations involve unexpected falls and trauma or pain from a chronic source.
When the ER staff calls me, the patient has been registered, insurance has been checked, medications have been reviewed, as have allergies to medication, and the patient has been evaluated by nurses and physicians. The patient’s record is a mix of paper documents and electronic health records. The hospital recently instituted a new electronic health record system with inadequate staff training and support (in my opinion) with decisions for financial reasons. The result is that most clinicians are constantly searching for information and not quite sure where all of it is. There is still a loose-leaf binder type shell for some daily paper information such as the EKG rhythm strips created on the telemetry monitors. Where a State of Florida DNR form is kept is anyone’s guess. I took the electronic health record training course online and the two in-person events. At no time did they discuss entering a code status or show us how to enter this data.
It seems to me that the question of a patients “code status” is something that should be asked at registration in the ER and at elective pre-admission. All patients should be considered a full and complete code unless they say otherwise and can produce the documentation needed. If they are not carrying the documents with them, then the document should be re-executed and signed at the registration desk by the patient or their legal health care surrogate. When their physician shows up to admit them the document should be on the chart, filled out for us to see. I can access my office patient files at the emergency department from my iPad but, due to lack of interoperability between electronic health records in the office and the hospital, I have no way to print out the document from my office electronic health record while I am at the hospital.
If end of life issues have not been discussed with the patient prior to hospitalization, I have no problem beginning the conversation when the medical condition they are there with has been addressed and stabilized.
It turns out that the email was addressed to the entire medical staff and not directed at me alone. None of the 25 charts reviewed by the Joint Commission were mine. If administration wishes to fix the problem it needs to make sure its employed clerical staff are trained to ask the right questions and list the answers where the doctors and nurses can easily see them and interpret them and act on them if necessary. Don’t ask caregivers to be data entry clerks for the Joint Commission or anyone else.
Leave us free to provide health care.
Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.
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