Gustafson Y, Brännström B, Norberg A, Bucht G, Winblad B
Department of Geriatric Medicine, University of Umeå, Sweden.
J Am Geriatr Soc. 1991 Aug;39(8):760-5. doi: 10.1111/j.1532-5415.1991.tb02697.x.
To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture.
The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies.
Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital.
Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively).
All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients.
ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.
确定髋部骨折患者病历中急性意识模糊状态（ACS）的诊断准确性及记录情况。
将两项前瞻性临床研究中ACS的诊断与其在同一患者同一住院期间病历中的诊断进行比较。为了确定同时进行的前瞻性研究是否会影响病历中所显示的诊断和记录行为，通过回顾前瞻性研究数年前诊治的两组患者的病历进行了进一步比较。
大学医院骨科治疗的股骨颈骨折患者，以及县医院普通外科的一个回顾性对照样本。
两个前瞻性样本，分别为65岁及以上接受股骨颈骨折治疗的患者（分别为n = 111和n = 57），以及两个早期回顾性样本（分别为n = 66和n = 68）。
所有比较均显示，医生和护士对ACS的诊断均不令人满意，对患者精神状态的记录也很差。对两个回顾性病历对照样本的分析得出了相同的结果。医生和护士均未使用任何诊断工具来检测患者的认知障碍。
ACS是股骨颈骨折老年患者常见且严重的并发症。根据定义，急性意识模糊状态有一个或多个通常可被识别和治疗的病因。评估和记录不佳对患者构成威胁，因为正确诊断ACS是进一步评估其潜在病因以及后续必要医疗和护理的前提条件。
