Documentation of delirium in the VA electronic health record View Full Text


Ontology type: schema:ScholarlyArticle      Open Access: True


Article Info

DATE

2014-04-03

AUTHORS

Carol Hope, Nicollete Estrada, Charlene Weir, Chia-Chen Teng, Kavitha Damal, Brian C Sauer

ABSTRACT

BACKGROUND: Delirium is a life-threatening, clinical syndrome common among the elderly and hospitalized patients. Delirium is under-recognized and misdiagnosed, complicating efforts to study the epidemiology and construct appropriate decision support to improve patient care. This study was primarily conducted to realize how providers documented confirmed cases of delirium in electronic health records as a preliminary step for using computerized methods to identify patients with delirium from electronic health records. METHODS: The Mental Health Consult (MHC) team reported cases of delirium to the study team during a 6-month study period (December 1, 2009 - May 31, 2010). A chart extraction tool was developed to abstract documentation of diagnosis, signs and symptoms and known risk factors of delirium. A nurse practitioner, and a clinical pharmacist independently reviewed clinical notes during each patients hospital stay to determine if delirium and or sign and symptoms of delirium were documented. RESULTS: The MHC team reported 25 cases of delirium. When excluding MHC team notes, delirium was documented for 5 of the 25 patients (one reported case in a physician's note, four in discharge summaries). Delirium was ICD-9 Coded for 7 of the 25 cases. Signs and symptoms associated with delirium were characterized in 8 physician notes, 11 discharge summaries, and 14 nursing notes, accounting for 16 of the 25 cases with identified delirium. CONCLUSIONS: Documentation of delirium is highly inconsistent even with a confirmed diagnosis. Hence, efforts to use existing data to precisely estimate the prevalence of delirium or to conduct epidemiological studies based on medical records will be challenging. More... »

PAGES

208-208

References to SciGraph publications

  • 2008-02-26. Detection of delirium by nurses among long-term care residents with dementia in BMC NURSING
  • 2008-09. Delirium: Underrecognized and undertreated in CURRENT TREATMENT OPTIONS IN NEUROLOGY
  • Identifiers

    URI

    http://scigraph.springernature.com/pub.10.1186/1756-0500-7-208

    DOI

    http://dx.doi.org/10.1186/1756-0500-7-208

    DIMENSIONS

    https://app.dimensions.ai/details/publication/pub.1013621218

    PUBMED

    https://www.ncbi.nlm.nih.gov/pubmed/24708799


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