Table 1 Consensus criteria to assess the frequency and quality of delirium documentation in discharge summaries
From: The frequency and quality of delirium documentation in discharge summaries
JCAHO requirementa | Consensus criteria specific for delirium |
|---|---|
Reason for Hospitalizationb | |
Chief complaint AND/OR HPI | Documentation of delirium as a chief complaint Documentation of the HPI for delirium episode |
Significant Findings | |
Primary diagnosis | Documentation of delirium as a primary diagnosis (if delirium was the reason for admission) Documentation of delirium as a secondary diagnosisc |
Procedures Performed | |
Hospital course AND/OR Hospital consults AND/OR Hospital procedures | Documentation of delirium in a problem list format Documentation of the onset of delirium Documentation of the cause of delirium Documentation of any specialist’s consultations in managing the delirium Documentation of completed delirium work-up investigations Documentation of received treatments for the primary cause of delirium |
Patient’s Condition at Discharge | Documentation of current state of delirium (resolved or not) Documentation of patient’s functional status at discharge |
Patient/Family Instructions | |
Discharge medications AND/OR Activity orders AND/OR Therapy orders AND/OR Dietary instructions AND/OR Plans for medical follow-up | Documentation of counselling/education provided to patient’s family or caregiver regarding delirium Documentation of medication changes, as relevant to delirium Documentation of rationale for medication changes for delirium Documentation of recommended medication follow-up for delirium Documentation of recommended cognitive follow-up for delirium Documentation of any referrals/follow-up with specialists for delirium Documentation of patient’s primary care provider |
Physician Signature | Documentation of electronic signature of discharge summary author |