Milisen Koen, Foreman Marquis D, Wouters Bert, Driesen Ronny, Godderis Jan, Abraham Ivo L, Broos Paul L O
Katholieke Universiteit Leuven, Faculty of Medicine, Center for Health Services and Nursing Research, Kapucijnenvoer 35, 4th Floor, 3000 Leuven, Belgium.
J Gerontol Nurs. 2002 Nov;28(11):23-9. doi: 10.3928/0098-9134-20021101-07.
This study determined the accuracy of diagnosis and documentation of delirium in the medical and nursing records of 55 elderly patients with hip fracture (mean age = 78.4, SD = 8.4). These records were reviewed retrospectively on a patient's discharge for diagnosis of delirium, and for description of clinical indicators or symptoms of delirium. Additionally, all patients were monitored by one of the research members on days 1, 3, 5, 8, and 12 postoperatively for signs of delirium, as measured by the Confusion Assessment Method (CAM). Clinicians were blinded to the purpose of the study. According to the CAM criteria, the incidence of delirium was 14.5% on postoperative Day 1; 9.1% on postoperative Day 3; 10.9% on postoperative Day 5; 7.7% on postoperative Day 8; and 5.6% on postoperative Day 12. For those same days, no formal diagnosis of delirium or a description of clinical indicators was found in the medical records. In the nursing records, a false-positive documentation of 8.5%, 4%, 4.1%, 4.2%, and 5.9%, respectively was noted. False-negative documentation was found in 87.5%, 80%, 66.7%, 75%, and 50% of the cases on the respective days. Documentation of essential symptoms--namely onset and course of the syndrome--and disturbances in consciousness, attention, and cognition, were seldom or never found in the nursing records. However, behaviors of the hyperactive variant of delirium and which are known to interfere with nursing care were documented more often (e.g., 13.4% restless, 10.3% fidget with materials, 7.2% annoying behavior). Both medical and nursing records showed poor documentation and under-diagnosis of delirium. However, a correct diagnosis and early recognition of delirium may enhance the management of this syndrome.
本研究确定了55例老年髋部骨折患者（平均年龄=78.4岁，标准差=8.4岁）医疗和护理记录中谵妄诊断及记录的准确性。在患者出院时回顾这些记录，以诊断谵妄，并描述谵妄的临床指标或症状。此外，所有患者在术后第1、3、5、8和12天由一名研究人员进行监测，采用意识错乱评估法（CAM）测量谵妄迹象。临床医生对研究目的不知情。根据CAM标准，术后第1天谵妄发生率为14.5%；术后第3天为9.1%；术后第5天为10.9%；术后第8天为7.7%；术后第12天为5.6%。在相同日期，医疗记录中未发现谵妄的正式诊断或临床指标描述。在护理记录中，分别发现假阳性记录为8.5%、4%、4.1%、4.2%和5.9%。在相应日期的病例中，分别有87.5%、80%、66.7%、75%和50%发现假阴性记录。护理记录中很少或从未发现该综合征基本症状的记录，即综合征的发作和病程以及意识、注意力和认知障碍。然而，谵妄多动型的行为，且已知会干扰护理的行为记录更为频繁（例如，13.4%躁动不安，10.3%摆弄物品，7.2%行为烦人）。医疗和护理记录均显示谵妄记录不佳且诊断不足。然而，正确诊断和早期识别谵妄可能会改善该综合征的管理。
