Hospital admission presents an important opportunity to engage with patients about goals of care (GOC) and advanced care planning. The significant and sensitive nature of GOC conversations requires that documentation of a patient’s goals be accurate, clear, and easily found in the medical record. This has become increasingly relevant in the setting of frequent provider hand-offs of care due to restricted duty hours and the movement of patients across different care settings. Through a gap analysis, we determined that at our academic medical center only 50% of inpatients with do-not-resuscitate (DNR) code status orders—including “do-not-resuscitate/do-not-intubate,” “do-not-resuscitate/comfort measures only,” “do-not-resuscitate/do-not-escalate,” and “partial code”—had GOC documented in a corresponding “Goals of Care” note. These dedicated notes are specifically designed to document GOC and are easily searched in the electronic health record (EHR). 


To improve rates of dedicated “Goals of Care” notes for patients with DNR code statuses to enhance interprovider communication of goals of care for inpatients


A root cause analysis was conducted through interviews with house staff in internal medicine, neurology, neurosurgery, hematology, oncology, and medical, surgical, and cardiac intensive care. Inpatients on these services who had DNR code statuses yet lacked a GOC note were first identified by chart review. We next performed structured, standardized interviews of the house staff caring for these patients to elicit the reasons behind this omission. Key drivers for poor documentation were lack of standard work, including ambiguity about when to document a GOC note and which team member was responsible for documentation, a cumbersome GOC note template, and forgetting to write the note. A standard workflow was developed that identified the team resident as responsible for ensuring a GOC note was written for all patients with DNR code statuses, with all notes requiring attending physician co-signature. A simplified GOC note template was created to support the new workflow. Finally, we created a Best Practice Alert (BPA) in our EHR to remind house staff to place GOC notes. This BPA was a non-interruptive reminder that appeared on the home screen (opening screen) of the EHR when a patient had a DNR code status order but no GOC note for the current inpatient encounter. The BPA also linked to educational information on this project as well as resources on how to conduct a GOC conversation. After the project was implemented, rates of GOC notes for DNR patients improved to 60% at one month, with data collection ongoing.  


At our academic medical center, we improved use of designated “Goals of Care” notes for patients with DNR code statuses through creation of a standardized workflow and implementation of a non-interruptive EHR-based alert.