The Importance of Complete Code Documentation

There are around 290,000 in-hospital cardiac arrests (IHCA) ¹ in the U.S. every year. Accurate documentation of resuscitation and code blue care is crucial. When the code is over, the report needs to be transcribed into the hospital EMR, which becomes a legal part of the patient’s record. Facts related to the in-hospital cardiac arrest (IHCA) may be incomplete or inaccurate if part of the notes is illegible or misplaced. The patient record that is generated during a code blue has three critical functions:

  1. The record is a real-time patient management aid during the event and serves as a road map for post-event care.
  2. The data collected serves as a rich source for directing quality improvement efforts.
  3. If acquired accurately, the record is the single best picture for reconstructing the event if risk management issues arise.

According to a Resuscitation Journal Study,² a freestanding clinical document was absent in 50% of patients’ records. Any event in which a medical record containing Personal Identifiable Information (PII) disappears constitutes a HIPAA violation. Your facility may not be providing adequate patient care if the documentation is not promptly placed into the EMR. Providing accurate documentation allows clinical teams to prove standardized care was given, helping avoid legal ramifications. In a way, code blue documentation needs to be so detailed that it “paints a picture” for those not administering the care.

So how do you ensure that a Code is documented in its entirety? In many hospital areas, clinical and technological improvements have enhanced outcomes. However, the equipment, operations, and technology that support Code Blue care have remained mostly unchanged for decades. A lack of change is likely one reason IHCA mortality rates remain persistently high. An electronic Code document makes it easier to relay crucial clinical information between providers, patients’ loved ones, and other departments efficiently and effectively so that critical data is not lost and the care is not compromised.

Handwritten code documentation notes are prone to error. Electronic documentation tools exist within some EMR systems, but they are often cumbersome and not created for a code’s fast-paced environment. Unlike a desktop computer, a mobile electronic system allows code teams to be almost instantly at a patient’s bedside.

RevitalPro, a tablet-based code blue guidance and documentation system enables code teams to administer standardized care while capturing complete data of the code. RevitalPro simultaneously guides teams to provide guideline-compliant care via metronomes, dosage calculators, timers, and prompts to keep time, record compressions, medications, and document every intervention. RevitalPro’s electronic documentation delivers a time-stamped, detailed document that can be used for debriefing, hospital reporting and instantly integrated into the hospital EMR for additional patient treatment within minutes after the code has ended.

In an Emergency Medicine Journal Study,³ documentation with an electronic system captured 24% more critical information during a simulated medical emergency without loss in data quality compared to paper documentation. Electronic Code documentation ensures an accurate and complete record immediately available to providers at all stages of patient care while providing vital reporting data for the organization, helps eliminate lost records, and eases information retrieval.