What do doctors record in the medical notes following discussion with the parents of sick premature infants?

Abstract

In a retrospective review of medical notes we determined: (1) how often doctors record discussions with the parents of very low birth weight (VLBW) infants during the neonatal period; (2) what details of any discussion they actually record and; (3) if they are more likely to record discussion with the parents of sicker infants. A random sample (30%) of all VLBW infants admitted between 1989 and 1993 to a regional NICU was reviewed, n = 87. No discussion was documented in 47 cases, one of whom died, 24 had a single episode of discussion recorded and 16 had two or more episodes recorded. Specific discussion about prognosis was only recorded in the notes of 27 babies. Discussion was more likely to be documented in sicker infants as measured by CRIB (clinical risk index for babies) score, t = −3.9, P<0.001.

Conclusion A record of discussion between medical staff and parents is found in the medical notes of less than half of all VLBW infants. These findings may have practical, ethical and legal implications.