Dignam Colette, Brown Margaret, Thompson Campbell H
Royal Adelaide Hospital, Adelaide, South Australia, Australia.
School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
Australas J Ageing. 2019 Mar;38(1):28-32. doi: 10.1111/ajag.12587. Epub 2018 Sep 21.
To compare 2011 and 2017 documentation of resuscitation decisions in older patients, including the frequency and clarity of documentation.
The clinical case notes of 130 patients aged 70 years and over were examined to identify how resuscitation decisions are discussed and documented at a major teaching hospital. Results were compared to 2011 data.
The proportion of patients with a documented order significantly increased, from 34 to 63%, with a concurrent increased number of patients identified as Not For Cardiopulmonary Resuscitation (Not for CPR). The standardised documentation has also improved rates of documented discussion, legibility and identification of the involved doctor.
The Resuscitation Plan 7-Step Pathway has markedly improved the frequency of documented discussion, the rate of recorded Not For CPR status and clarity of documentation. There is scope for improvement as this policy is embraced across South Australia.
比较2011年和2017年老年患者复苏决策的记录情况，包括记录的频率和清晰度。
检查了130名70岁及以上患者的临床病例记录，以确定在一家大型教学医院中复苏决策是如何讨论和记录的。将结果与2011年的数据进行比较。
有记录医嘱的患者比例显著增加，从34%增至63%，同时被确定为不进行心肺复苏（不进行CPR）的患者数量也有所增加。标准化记录还提高了记录讨论的比例、易读性以及相关医生的辨识度。
复苏计划7步法显著提高了记录讨论的频率、记录的不进行CPR状态的比例以及记录的清晰度。随着该政策在南澳大利亚州的推行，仍有改进空间。
