Question: Where do long-term care nurses document the steps taken in a full code?
Answer: No clue – there is no standard.
After giving this some thought, I asked myself, “Why not?” Why do professional nurses who are required to be certified in CPR and initiate life sustaining measures in the event of a full code, not document what was done? Great question!
I remember being a DON in a skilled nursing facility when a full code was called. After evaluating the situation and determining that the code was being handled appropriately, I grabbed a Kleenex box, flipped it over and started documenting the time, what was being done, who was performing chest compressions, who was managing the airway/respiratory support, when 911 was called, etc. At the end of the day, this information was transcribed onto a summary sheet and reviewed by the QA committee to determine if there were any areas needing improvement.
Was this a standard? No, but it was what we did and continued to do whenever a code was called. Historically nurses have been known to write on their hands, arms, napkins, paper towel or whatever they could use to document important findings immediately. Remember, every minute that passes before events are documented increases the risk for errors/omissions. If you have ever looked at the top of a medication cart, inevitably you will see a folded paper towel with room numbers and vital signs documented on it, or maybe the time a tube feeding was hung, when it is time to hang a piggy back IV, etc. These are the “Kleenex boxes” for the nurse on duty, the way things are tracked when the medical record isn’t available. Although this isn’t a recommended practice, it is a better option than a very busy nurse’s memory!
The importance of documenting everything from the multivitamin administered with am medications to a treatment performed is stressed in every nurse training session; however, when it comes to possibly the most important care we will ever provide we fall short in documentation.
What do you think? Does your facility have a protocol/best practice/standard for documentation during a full code? HealthCap recommends that you discuss this with your Quality Assurance Committee and Medical Director. If it is decided that this would be a good practice for your facility, remember to keep it simple, don’t make the form so difficult that staff won’t be compliant or worse, leave blanks on the form. Be sure your policy reflects facility expectations clearly with little room for misinterpretation. Educate staff on the policy and form, stressing the importance of compliance, and as always, feel free to contact your HealthCap Risk Manager for assistance!