Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic Health Records

Viral G Jain; Peter J Greco; David C Kaelber

doi:10.4338/ACI-2016-08-RA-0133

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2017; 08(01): 226-234
DOI: 10.4338/ACI-2016-08-RA-0133

Research Article

Schattauer GmbH

Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic Health Records

Authors

Viral G Jain

¹Department of Pediatrics, The MetroHealth System, Case Western Reserve University, Cleveland OH

²Division of Neonatology and Pulmonary Biology, Cincinnati Childrens Hospital, Cincinnati OH
Peter J Greco

³Department of Internal Medicine, The MetroHealth System, Case Western Reserve University, Cleveland OH

⁴Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland OH

⁵Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland OH
David C Kaelber

¹Department of Pediatrics, The MetroHealth System, Case Western Reserve University, Cleveland OH

³Department of Internal Medicine, The MetroHealth System, Case Western Reserve University, Cleveland OH

⁴Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland OH

⁵Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland OH

Abstract

Full Text

PDF Download

Keywords

Code status - advance directive - meaningful use - reconciliation - medication - DNR

References

References
1 Temel JS, Greer JA, Admane S, Solis J, Cashavelly BJ, Doherty S, Heist R, Pirl WF. Code status documentation in the outpatient electronic medical records of patients with metastatic cancer. J Gen Intern Med 2010; 25 (Suppl. 02) 150-153.
2 Collier KS, Kimbrel JM, Protus BM. Medication appropriateness at end of life: a new tool for balancing medicine and communication for optimal outcomes--the BUILD model. Home Healthc Nurse 2013; 31 (Suppl. 09) 518-524.
3 Bates D. Draft Recommendations Meaningful Use Stage 3. 2013 [Accessed 10/18/16]; Available from: https://www.healthit.gov/FACAS/sites/faca/files/muwg_stage3_draft_rec_07_aug_13_.v3.pdf
4 Weinerman AS, Dhalla IA, Kiss A, Etchells EE, Wu RC, Wong BM. Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med 2015; 10 (Suppl. 08) 491-496.
5 Bhatia HL, Patel NR, Choma NN, Grande J, Giuse DA, Lehmann CU. Code status and resuscitation options in the electronic health record. Resuscitation 2015; 87: 14-20.
6 Neubauer MA, Taniguchi CB, Hoverman JR. Improving incidence of code status documentation through process and discipline. J Oncol Pract 2015; 11 (Suppl. 02) e263-e266.
7 Schiebel N, Henrickson Parker S, Bessette RR, Cleveland EJ, Neeley JP, Warfield KT, Barth MM, Gaines KA, Naessens JM. Honouring patient’s resuscitation wishes: a multiphased effort to improve identification and documentation. BMJ Qual Saf 2013; 22 (Suppl. 01) 85-92.
8 EMRAM Stage Criteria.. 2015 [Accessed 10/15/16]; Available from: http://www.himssanalytics.org/research/emram-stage-criteria
9 Campbell R. The five ,,rights“ of clinical decision support. J AHIMA 2013; 84 (Suppl. 10) 42-47 quiz 48.
10 Heffner JE, Barbieri C. Compliance with do-not-resuscitate orders for hospitalized patients transported to radiology departments. Ann Intern Med 1998; 129 (Suppl. 10) 801-805.
11 Sehgal NL, Wachter RM. Identification of inpatient DNR status: a safety hazard begging for standardization. J Hosp Med 2007; 2 (Suppl. 06) 366-371.
12 Ardagh M. Futility has no utility in resuscitation medicine. J Med Ethics 2000; 26 (Suppl. 05) 396-399.
13 Kumar P, Temel JS. End-of-life care discussions in patients with advanced cancer. J Clin Oncol 2013; 31 (Suppl. 27) 3315-3319.
14 Kernerman P, Cook DJ, Griffith LE. Documenting life-support preferences in hospitalized patients. J Crit Care 1997; 12 (Suppl. 04) 155-160.
15 Mack JW, Cronin A, Taback N, Huskamp HA, Keating NL, Malin JL, Earle CC, Weeks JC. End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med 2012; 156 (Suppl. 03) 204-210.
16 Greenwald JL, Halasyamani L, Greene J, LaCivita C, Stucky E, Benjamin B, Reid W, Griffin FA, Vaida AJ, Williams MV. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med 2010; 5 (Suppl. 08) 477-485.