Background: Hospitalists have an increasing role in caring for patients with advanced illness. Due to time constraints, lack of experience and the sensitivity of the topic, it is challenging for Hospitalists to engage in adequate conversations regarding advanced care planning. Moreover, when these conversations do occur, documentation of Advanced Directives and Code Status is frequently difficult to locate in the Electronic Health Record (EHR), inconsistent between encounters and incomplete. This lack of documentation can then lead to end of life care at odds with a patient’s wishes.
Methods: A sample of patients from the hospitalist service from January to May of 2017 had their charts reviewed for presence of code status documentation, Palliative Care consultation, presence of scanned Advanced Directives and discordance between the notes and documentation. The History and Physicals, Discharge Summaries and key Progress Notes (first and last note, at transitions of care, and on days of code status order entry) written by the primary team were reviewed. The training level and specialty of the documenting provider was recorded. The initial Emergency Room Note, Palliative Care initial and final consultation notes were reviewed for code status discussions. The date of scanned Advanced Directives for encounters were recorded as being before, during or after admission. Discordance in documentation was noted to be present if there was documentation of two different code statuses on overlapping days, documentation of a code status that was inconsistent with advanced directive scanned, documentation of one code status with order of another code status, or nursing documentation of no advanced directive in patient that has an Advanced Directive scanned.
Results: 840 encounters involving 572 patients on the Hospital Medicine Service (HMS) between January and May 2017 were manually reviewed. 398 (47.4%) had code status documented. The Intensive Care Unit (ICU) provider recorded the code status in 119 (29.9%) encounters, 16 (4.0%) were documented by palliative care, and 265 (66.6%) were documented by HMS. Of those documented by HMS, 113 (42.6%) were documented by the resident, 35 (13.2%) by the Advanced Practice Provider (APP), and 114 (43.0%) by the attending. At our hospital, 16% of patients are seen by teams with residents and 14% by APP teams. Discordance was present in 19 (4.8%) of documented encounters. Of these 19, 12 (63.2%) had advanced directives scanned that were not noted by the primary team.
Conclusions: Hospitalists are not currently documenting code status in the majority of patients admitted to their service. Predictors of documentation are being assessed including severe comorbidities, presence of ICU stay, age of patient and presenting diagnosis to begin to formulate strategies for reversing this trend. Educational interventions and EHR tools are being developed to improve documentation practices.