243 An Audit of Documentation of Resuscitation Status in a Teaching Hospital

Background The documentation of discussions about resuscitation status with patients and their relatives is an important part of medical care, but can be a time-consuming process. These discussions may be difficult, particularly for patients who have cognitive impairment or are acutely unwell. The National Consent Policy1 recommends that resuscitation decisions should be made with patients themselves, or with family members if the patient cannot participate. It also recommends decisions are made by the most senior decision maker with responsibility for the patient’s care and discussions should be carefully documented. Methods The charts of all 106 inpatients in our hospital were audited on a single day. Documentation of resuscitation status in the medical and nursing notes was reviewed. Results The average age of inpatients was 79.8 years. 25.5% of patients had a DNACPR order. Of these, 92% had their DNACPR status documented in the nursing notes. 100% had a DNACPR form in their medical notes but none were fully completed. 48% had not had the decision endorsed by the consultant in charge of the patient’s care. 74% had not been discussed with the patient or had not had a reason documented as to why the decision had not been discussed. 41% did not have any discussion documented in the medical notes. Conclusion The DNACPR form in use includes the details recommended by national guidelines but these forms are not being completed in their entirety. Discussions with patients themselves are possibly inappropriate at the time resuscitation status is being considered, but documentation of the reasons for this is still important. This, in particular is an area which needs to be highlighted to medical staff in our hospital. Results of this audit will be incorporated into an education session, with a view to changing practice.