10. Quality of medical records and audit

Entries in medical records

It is clear that the quality of the medical record was poor and not in keeping with current guidance and that significant improvement is required ^37,38,39.

*Contact details = at least two of the following:
Name
Bleep number
Grade

It has been recommended that patients at risk of deterioration should have their resuscitation status considered early in their care. The General Medical Council is quite clear in this regard -

"Where a patient is already seriously ill with a foreseeable risk of cardiopulmonary arrest, or a patient is in poor general health and nearing the end of their life, decisions about whether to attempt CPR [cardiopulmonary resuscitation] in particular circumstances ideally should be made in advance as part of the care plan for that patient. A patient's own views, about whether the level of burden or risk outweighs the likely benefits from successful CPR, would be central in deciding whether CPR should be attempted. It is important in these cases to offer competent patients or, if a patient lacks capacity to decide, those close to the patient, an early opportunity to discuss their future care and the circumstances in which CPR should or should not be attempted" ⁴⁰.

A more recent joint publication also emphasises the importance of decisions relating to resuscitation status ⁴¹.

Such actions will allow for a clear plan of management in the event of deterioration. This is especially important as the impact of shift working has reduced continuity of care significantly and it is less likely that a member of the medical team who knows the patient will be present.

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