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Table 3 Quality components of delirium documentation in discharge summaries

From: The frequency and quality of delirium documentation in discharge summaries

Quality component

n (%)a

Total (n = 110)

Medicine (n = 59)

Surgery (n = 51)

p-valueb

Documented as chief complaint or HPI

31/47 (66.0)

29/42 (69.0)

2/5 (40.0)

0.32

Documented as diagnosis

 “Delirium”

34/110 (30.9)

22/59 (37.3)

12/51 (23.5)

0.18c

“Delirium” or other term

46/110 (41.8)

34/59 (57.6)

12/51 (23.5)

< 0.001d

 Not documented

64/110 (58.2)

25/59 (42.4)

39/51 (76.5)

 

Documented as 1º diagnosise

23/38 (60.5)

21/34 (61.8)

2/4 (50.0)

1.00

Documented as 2º diagnosise

23/72 (31.9)

13/25 (52.0)

10/47 (21.3)

0.02

Documented in problem liste

35/110 (31.8)

26/59 (44.1)

9/51 (17.6)

0.01

Documented delirium onset

70/110 (63.6)

41/59 (69.5)

29/51 (56.9)

0.24

Documented delirium etiology

51/84 (60.7)

38/54 (70.4)

13/30 (43.3)

0.03

Documented consulting service involvement

21/55 (38.2)

9/27 (33.3)

12/28 (42.9)

0.65

Documented delirium work-up

45/106 (42.5)

34/59 (57.6)

11/47 (23.4)

0.001

Documented delirium treatment

47/84 (56.0)

36/54 (66.7)

11/30 (36.7)

0.02

Documented delirium status at discharge

56/84 (66.7)

30/46 (65.2)

26/38 (68.4)

0.94

Documented functional status at discharge

37/110 (33.6)

17/59 (28.8)

20/51 (39.2)

0.34

Documented relevant medication changes

20/25 (80.0)

16/16 (100.0)

4/9 (44.4)

0.002

Documented reason for medication changes

14/25 (56.0)

12/16 (75.0)

2/9 (22.2)

0.02

Documented patient or family instructions

52/110 (47.3)

23/59 (40.0)

29/51 (56.9)

0.06

Documented any follow-up recommendations

19/28 (67.9)

15/17 (88.2)

4/11 (36.4)

0.01

Documented follow-up for psychoactive medications

9/12 (75.0)

9/9 (100.0)

0/3 (0.0)

0.01

Documented follow-up for cognitive status

5/11 (45.5)

3/5 (60.0)

2/6 (33.3)

0.57

Documented follow-up with specialist

8/10 (80.0)

6/6 (100.0)

2/4 (50.0)

0.13

Copied to primary care provider

89/110 (80.9)

54/59 (91.5)

35/51 (68.6)

0.01

Signed by author

110/110 (100.0)

59/59 (100.0)

51/51 (100.0)

 
  1. Denominators for each quality component differed, depending on its applicability to the patient. For instance, if no changes were made to psychoactive medications, then this would not be applicable and expected to be documented in the discharge summary
  2. aComponents based on the JCAHO requirements for a quality discharge summary, as defined by Kind et al. [19] and made specific for delirium. See Additional File 2 for full definitions developed specifically for delirium
  3. bComparing medicine vs. surgery
  4. cWhen compared to grouped data from other term and no delirium documentation
  5. dWhen compared to no delirium documentation
  6. eDocumentation of the term “delirium” or other term
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BMC Geriatrics

ISSN: 1471-2318

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