WHAT DO DOCTORS RECORD IN THE MEDICAL NOTES FOLLOWING DISCUSSION WITHTHE PARENTS OF SICK PREMATURE-INFANTS

In a retrospective review of medical notes we determined: (1) how ofte n doctors record discussions with the parents of very low birth weight (VLBW) infants during the neonatal period; (2) what details of any di scussion they actually record and; (3) if they are more likely to reco rd discussion with the parents of sicker infants. A random sample (30% ) of all VLBW infants admitted between 1989 and 1993 to a regional NIC U 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 ha d two or more episodes recorded. Specific discussion about prognosis w as 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 n otes of less than half of all VLBW infants. These findings may have pr actical, ethical and legal implications.