The frequency and quality of delirium documentation in discharge summaries

• Published in: BMC geriatrics 2021-05, Vol.21 (1), p.307-307, Article 307
• Main Authors: Chuen, Victoria L, Chan, Adrian C H, Ma, Jin, Alibhai, Shabbir M H, Chau, Vicky
• Format: Article
• Language: English
• Subjects: Admission and discharge; Bone surgery; Care and treatment; Delirium; Discharge summary; Documentation; Etiology; Geriatrics; Hospital patients; Hospitals; Hypotheses; Medical care; Methods; Older people; Patients; Quality; Quality management; Statistics
• ISSN: 1471-2318; 1471-2318
• DOI: 10.1186/s12877-021-02245-3

The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary. We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p