Journal of the American Medical Informatics Association : JAMIA
-
J Am Med Inform Assoc · Sep 2004
Electronic screening of dictated reports to identify patients with do-not-resuscitate status.
Do-not-resuscitate (DNR) orders and advance directives are increasingly prevalent and may affect medical interventions and outcomes. Simple, automated techniques to identify patients with DNR orders do not currently exist but could help avoid costly and time-consuming chart review. This study hypothesized that a decision to withhold cardiopulmonary resuscitation would be included in a patient's dictated reports. The authors developed and validated a simple computerized search method, which screens dictated reports to detect patients with DNR status. ⋯ Dictated hospital reports frequently contained DNR order-related information for patients with a written DNR order. Using an uncomplicated keyword search, electronic screening of dictated reports yielded good accuracy for identifying patients with DNR order information.