The challenge for good documentation during a Code…

The confusion and urgency of most resuscitation efforts prohibit accurate event documentation. Do any of these statements describe code documentation in your institution?

• Code documentation does not start when the patient is found in arrest, but rather begins sometime later during the resuscitation.
• The least experienced staff member present at a code is asked to document, e.g., student, new nurse.
• The person documenting is unfamiliar with the CPR record and data requested.
• The job of documentation during a code is not considered one of the key, desirable roles.
• Several different clocks are used to enter times onto the CPR record.
• The data on the CPR record is incomplete.
• The data on the CPR record is often illegible.
• The names of all CPR members are not present on the CPR record.The CPR record may not make it back to the CPR committee for review.

For code documentation to become accurate and complete, it must be valued. This starts with the CPR committee making the decision to document according to the American Heart Association recommendations, and then creating a CPR record with the required data elements – or choosing an electronic method for documentation.