Accuracy of nurse documentation of delirium symptoms in medical charts

Abstract

The purpose of this study undertaken in an acute care hospital was to evaluate sensitivity and specificity of the documentation of nurse-reported delirium symptoms in medical charts. This is a descriptive study based on the clinical assessments of a study nurse and nursing notes in the medical charts of 226 delirious older patients newly admitted to an acute care hospital. The results of this prospective validation study indicated that documentation of delirium symptoms is poor. Disorientation, agitation and altered level of consciousness were the three symptoms yielding a higher level of sensitivity, but even so said symptoms were reported in less than a third of the medical charts. Univariate analysis suggested that higher comorbidity level, more severe symptoms of delirium and the use of physical restraints were associated with more valid documentation of delirium symptoms in medical charts. Lastly, this study corroborates results of previous studies, indicating that documentation of delirium symptoms in medical charts can be improved. Future study should target improving nurse documentation of delirium symptoms in medical charts.

The Incidence of Delirium at the Postoperative Intensive Care Unit in Adult Patients

“…Deliryum ciddi sonuçlara neden olan bir sendrom olup mortalite ve morbidite oranlarını artırdığı ve hastanede kalış süresini uzattı-ğı çalışma sonuçları ile gösterilmiştir (2,3). Erkek cinsiyet, alkol alışkanlığı, dehidratasyon, çoklu ilaç kullanımı, ağrı nöroleptik ve narkotik kullanılması gibi pek çok faktör deliryumu başlatabilir.…”

An evaluation of nursing documentation of acutely admitted older home-living medical patients in a Danish hospital

“…The missing association between patient impairment and nursing documentation has been observed earlier. [7,8] However, these studies differ in terms of the definition of documentation, as they examined the quality and if the documentation was accurate by studying the content of the documentation. This study broadly examines if documentation in a given area is made at all, looking at both unstructured notes and schemes.…”

“…[7,23,39] The best documented core area was nutrition, which is mandatory to document when hospitalized in Denmark and is a part of the accreditation process. When examining the unstructured notes in the nursing records for pain, cognitive level, and depression, we found a better documentation practice.…”

“…[17] In general, studies which have investigated congruence between patient records and patient-reported symptoms conclude a low agreement. [18,19] Studies on nursing documentation in elderly patients have been focused upon structured documentation of: functional ability, [20] nutrition, [21] pressure ulcers, [22,23] delirium, [7] and dementia. [24] In Denmark, nursing reports contain the possibility to document both structured and unstructured, such as free text notes.…”

“…[3][4][5] Even though documenting patient data has been a nursing task for more than 150 years, [6] and the exchange of information is a significant nursing activity, [3] documentation practices is still today an area of extensive challenges. [7][8][9][10][11] Increased requirements for documentation and demands to fulfill quality standards are a part of everyday practice in Danish hospitals, as patient treatment and trajectories are getting more complex. Increased documentation can be seen as a management tool, which is linked to the governing ambitions within the New Public Management, a market inspired public administration model, striving to make public institutions such as health care more efficient and productive through policy defined production targets.…”