Documentation of delirium in the VA electronic health recordReport as inadecuate

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BMC Research Notes

, 7:208

First Online: 03 April 2014Received: 20 August 2013Accepted: 25 March 2014DOI: 10.1186-1756-0500-7-208

Cite this article as: Hope, C., Estrada, N., Weir, C. et al. BMC Res Notes 2014 7: 208. doi:10.1186-1756-0500-7-208


BackgroundDelirium 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.

MethodsThe 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.

ResultsThe 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.

ConclusionsDocumentation 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.

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


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