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Accuracy of nurse documentation of delirium symptoms in medical charts

Authors

  • Philippe Voyer RN PhD,

    Corresponding author
    1. Associate Professor, Faculty of Nursing Sciences, Laval University and Geriatric Nurse Specialist, and Rearcher, Laval University Geriatric Research Unit at St-Sacrement Hospital Centre, Faculty of Nursing Sciences, Laval University, Quebec City, Quebec, Canada
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  • Martin G Cole MD FRCPC,

    1. Senior Psychiatrist, Department of Psychiatry, St. Mary's Hospital, and Professor, Department of Psychiatry, McGill University, St. Mary's Hospital Centre, Monteal, Quebec, Canada
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  • Jane McCusker MD DrPH,

    1. Head of the Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital Centre, and Professor, Department of Epidemiology, Biostatisics and Occupational Health, McGill University, St. Mary's Hospital Centre, Montreal, Quebec, Canada
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  • Sylvie St-Jacques PhD,

    1. Research Assistant, Laval University Geriatric Research Unit, St-Sacrement Hospital, Quebec City, Quebec, Canada
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  • Johanne Laplante RN MSc

    1. Clinical Nurse Specialist—Geriatric Psychiatry, St. Mary's Hospital, Montreal, Quebec, Canada
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Philippe Voyer, Faculté des sciences infirmières, Université Laval, Cité Universitaire, Québec City, Québec, Canada G1K 7P4. Email: philippe.voyer@fsi.ulaval.ca

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.

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