Documentation of Crucial Information Relating to Critically Ill Patients. J Palliat Care 2018 Jan;33(1):5-8
Date
12/21/2017Pubmed ID
29260613DOI
10.1177/0825859717746273Scopus ID
2-s2.0-85048535259 (requires institutional sign-in at Scopus site) 3 CitationsAbstract
BACKGROUND: Medical decision-making has evolved to the modern model of shared decision-making among patients, surrogate decision-makers, and medical providers. As such, informed consent discussions with critically ill patients often should include larger discussions relating to values and goals of care. Documentation of care options and prognosis serves as an important component of electronic communication relating to patient preferences among care providers.
OBJECTIVE: This retrospective chart review study sought to evaluate the prevalence of documentation of critical data, care options, prognosis, and medical plan, within primary team and palliative care consult team documentation.
RESULTS: Three hundred two electronic medical records were reviewed. There was a significant difference in documentation between palliative care and primary teams for prognosis (83% vs 32%, P < .001), care options (82% vs 50%, P < .001), and care plan (82% vs 46%, P < .001).
CONCLUSIONS: Our retrospective chart review study demonstrated a significant difference in documentation between primary and palliative care teams. We acknowledge that review of documentation cannot be extrapolated to the presence or absence of conversations between providers and patients and/or surrogates. Additional studies to evaluate this connection would be advantageous.
Author List
Bear A, Thiel EAuthors
Alexandria J. Bear MD Assistant Professor in the Medicine department at Medical College of WisconsinElizabeth Thiel MD Associate Professor in the Medicine department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AdultAged
Aged, 80 and over
Critical Care
Critical Illness
Decision Making
Documentation
Electronic Health Records
Female
Humans
Informed Consent
Male
Middle Aged
Palliative Care
Retrospective Studies
Young Adult
