HOSPITAL CODE DOCUMENTATION
Why Document a Patient’s Resuscitation Event?
The first and foremost reason for documentation of the code is that the CPR record is the medical record of all the interventions that occur during a resuscitation. But how does this record help the patient, family, clinician and institution? The CPR record has numerous benefits:
- It provides information that can guide continuing care for the patient.
- It helps to answer questions the family may have about the event.
- It assists the institution to know if resuscitation care has been provided according to current standards.
- It identifies quality issues so they can be investigated in a timely manner.
- It provides data that can be aggregated to describe the population undergoing resuscitation to determine if processes of care are delivered in the time intervals recommended by the American Heart Association, and to know if an institution’s outcomes are similar to those of like institutions.
- The aggregate data can be used to identify variances of concern and as the base for continuous quality improvement efforts.
- It provides data to evaluate whether Joint Commission standards are being met.
- It provides information to guide resource allocations related to personnel, equipment and supplies used during resuscitations.
- It helps to identify learning needs of staff.
- It can provide the data to answer research questions.
- It can reduce the risk of medical litigation.
What Data Elements Should Be Tracked for Resuscitation Events?
The American Heart Association recommended in 1997 the data elements that should be collected from resuscitations in the Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital ‘Utstein Style.’ An update was provided in 2004 with Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update and Simplification of the Utstein Templates for Resuscitation Registries. These documents include definitions of the data elements, directions for documenting and priority status for the data elements related to those that are “essential” and others that are “desirable.”
The data elements for collection can be divided into three categories of variables:
- Patient variables, e.g., age, gender, witness status, location of event, date/time of event, comorbid conditions
- Event variables, e.g., initial rhythm, essential interventions, event times
- Outcome variables, e.g., return of spontaneous circulation (for at least 20 minutes), discharge alive from the hospital, neurologic status at discharge, length of stay,
Several critical time elements should be documented:
- Time from collapse to the beginning of cardiopulmonary resuscitation (CPR)
- Time from collapse to first defibrillation when the initial rhythm is ventricular fibrillation or pulseless ventricular tachycardia
- Time from collapse to first dose of epinephrine
How Does an Institution Create a CPR Record?
You can certainly create your own CPR record that contains the data elements recommended by the American Heart Association. But why not start with the Standard Reporting of In-Hospital Cardiopulmonary Resuscitation form found as Figure 5 in the Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital ‘Utstein Style’?
Another good resource is the National Registry of CPR, who provide Medical Emergency/Rapid Reponse Teams code data forms in both PDF and Word formats:
- Adult Codesheet
- Neonate Codesheet
- Resuscitation Review Sheet (for documenting process problems related to the resuscitation)
A technologic advance by ZOLL Medical Corporation is CodeNet Writer, a PDA-based application that is used to document and automatically time-stamp-code events and download defibrillator data at the end of the code. Preprogrammed screens on the pocket PC provide automatic cues for data entry during and after a code. Data can be entered by using a stylus, scribbling on the electronic pad or speaking into the voice recorder. CodeNet Writer is linked with CodeNet Central, a PC-based application to manage, store and print case and aggregate CPR reports. A unique feature of this software program is that all times are synchronized to one clock – a first for code documentation!
The Challenge of Good Documentation During a Code
The confusion and urgency of most resuscitation efforts prohibit accurate event documentation. Do any of these statements describe code documentation in your institution?
- At times, it is not clear if a CPR record should be completed or not, e.g., when a patient is defibrillated yet no compressions are given, when a patient is given assisted ventilations yet no compressions are needed.
- Code documentation does not start when the patient is found in arrest, but rather begins sometime later during the resuscitation.
- The CPR record cannot always be quickly found to begin documentation.
- The least experienced staff member present at a code is asked to document, e.g., student, new nurse.
- The person documenting is unfamiliar with the CPR record and data requested.
- The job of documentation during a code is not considered one of the key, desirable roles.
- Several different clocks are used to enter times onto the CPR record.
- The data on the CPR record is incomplete.
- The data on the CPR record is often illegible.
- The names of all CPR members are not present on the CPR record.
- The CPR record may not make it back to the CPR committee for review.
For code documentation to become accurate and complete, it must be valued. This starts with the CPR committee making the decision to document according to the American Heart Association recommendations, and then creating a CPR record with the required data elements – or choosing an electronic method for documentation such as ZOLL CodeNet, with it all laid out.
The role of documenter should be assigned to a select group of trained individuals who are familiar with the data needed and how to obtain it. For example, the documenter may need to request that as any medication is administered IV push to the patient, the provider announce when it is “in” so that the time of documentation can be accurate. The documenter should have no other role during the resuscitation so that full attention can be given to collecting the needed data and following the multiple interventions that often occur simultaneously. It has even been suggested that the documenter have a designated position around the patient’s bed so that all providers will know where to target their information.
The CPR record should be kept in a designated location such as on the top of the code cart, so that it can be quickly found at the very beginning of a resuscitation. If CodeNet is not used to document synchronized times, then one clock should be agreed upon for documentation of all times during the resuscitation, e.g., the wall clock in the patient’s room. Summary information should always be obtained from the defibrillator and a method determined for how to make it a permanent part of the patient’s record. The original paper CPR record should be placed in the patient’s medical record, and a copy should be submitted to the CPR committee. Any quality feedback should not be placed in the medical record, but rather written on a form that is returned in a secure manner to the CPR committee and thus is protected from legal discovery according to state quality assurance statutes.
After each code, the CPR record should be reviewed for completeness and process of care, and feedback given to the providers for a job well done or improvement needed. Systems of care should change based on concerns reported so that staff see their input has been used to improve the quality of care. Aggregate code data should be presented to a variety of forums showing how their processes of care and outcomes compare to like institutions. Undesirable trends should be identified so priorities can be set and systems changed. (See "Evaluating Resuscitation Quality" for more information.)
If these elements of documentation are put in place for your institution, you will find that accurate and complete code documentation results in the benefits outlined in the first paragraph of this section.