Nurse

Hi,

could anyone tell me where do you find "Code status" for a patient in his chart...i mean under which TAB?

TIA

Generally, it will be in with other Legal papers. Every hospital has their own system for chart order, but it is usually at the front or back.

It used to be that DNR patients had orange DNR stickers on the spines of their charts. HIPAA did away with that though. Some facilities will use colored "dot" stickers to signify certain bits of key information at a glance, as a "code" that is still HIPAA-compliant.

Ours are placed under the tab called Advanced Directives. If the patient doesn't have any AD's on the chart the next thing I do is look on the admission orders and see if the Doctor addressed it there. I will then flip through all the orders and if I don't see it anywhere I assume they are a full code until I'm told otherwise. Does this help at all?

Thanks to both of you. i really appreciated ur quick response.

Ours are placed under the tab called Advanced Directives. If the patient doesn't have any AD's on the chart the next thing I do is look on the admission orders and see if the Doctor addressed it there. I will then flip through all the orders and if I don't see it anywhere I assume they are a full code until I'm told otherwise. Does this help at all?

Heh, I'd forgotten that code status is often addressed in Dr's orders, but it is. However, if possible, I'd like to see the advance directive/DNR form itself too.

Sometimes you can check the progress notes. I know it's not an official order, but you might see it there as well.

At the hospital where I do clinical, its included on the admission sheet in the chart and under admission history in the computer.