Documentation of Crucial Medical Information in Critically Ill Patients (S756)

•Elucidate the differences in documentation of key aspects of medical decision making.•Describe the implications of inadequate documentation of care choices as it relates to informed consent as well as inter-team communication. The medical record is one of the primary communication methods for patient information and is integral to patient care, inter-team communication, and care continuity. Documentation of prognosis and care options as they relate to medical decision making should ideally be in the medical record. There is little research on the documentation of discrete medical options, including disease-based treatments versus a comfort plan of care. Understand the current documentation practices for prognosis and medical options, at a large academic institution, by both primary and palliative teams. A retrospective chart review was completed on all patients for whom a Palliative consult was obtained and who required ventilator support, dialysis, or gastric tube. Both primary and palliative team documentation was evaluated for the following: notation of critical labs or imaging, prognosis, medical options, and plan as it relates to medical options in the 72 hours after a palliative consult. 114 patients were included in the study. Both teams documented critical test results in over 80% of the patients. In the primary team’s notes, prognosis was documented 31.6% of the time, medical options 50%, and documentation of the plan as it related to the options 46.4%. In the palliative notes, 83.3% contained documentation of prognosis, 81.6% contained documentation of medical options, and 81.6% contained documentation of the plan as it related to the options. The palliative care team documented prognosis, care options, and care plan significantly more than the primary teams. The lack of documentation in the medical record of both prognosis and medical options by the primary team can have significant impact of the ability to provide appropriate patient care, inter-team communication, and care continuity.