Diagnosing brain death: the importance of documenting clinical test results

Eighty-three cases of brain stem death referred to the South Thames Transplant Co-ordination Service were audited to determine the quality of brain stem death test records. Documentation of brain stem death tests were complete in only 41 (44%) cases at the time of referral. There was no significant difference in completeness, whether documentation was in patient's notes or on a designated checklist (p = 0.14). There were a greater number of omissions when the tests were documented in patient's notes rather than on a form (p = 0.01). There is a necessity to improve the quality of brain stem death test documentation in order to facilitate organ donation and safeguard the integrity of brain stem death testing. This requires a commitment by clinicians to improve the quality of documentation, which can be accomplished by recording all aspects of brain stem death tests, including the conclusion on a single designated checklist.