From the Department of Internal Medicine and Pediatrics, University of Buffalo, Buffalo, NY.
Department of Internal Medicine, Division of Hospital Internal Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota.
J Patient Saf. 2019 Dec;15(4):e40-e43. doi: 10.1097/PTS.0000000000000280.
The aim of the study was to determine how frequently mental status and mental status changes are documented in the written patient summary ("sign-out") provided to covering physicians.
This was a retrospective cohort study of general medical patients hospitalized between March 16, 2009, and March 15, 2010, conducted at 2 teaching hospitals. Participants included patients with mental status change adverse events (MSAEs) and their providers. Chart review was performed to identify patients with MSAEs and details about these events. Sign-outs were reviewed for documentation of mental status. Main outcome measures were (1) proportion of patients with MSAEs who had mental status ever recorded in sign-out entries and (2) the proportion of patients with MSAEs whose change in mental status was recorded in the sign-out.
Sixty-eight patients had MSAEs and were included in the sample. Fifty percent of MSAEs were attributed to medications; 75% of these events were first detected by nurses. Only 25% of patients with MSAEs had their change in mental status recorded in sign-outs.
Recording mental status in written sign-outs is uncommon. Particularly concerning is that patients with MSAEs identified by chart review seldom had sign-outs that reflected those events. Interventions should be designed to increase the recording of this information in sign-outs.
本研究旨在确定在提供给主治医生的书面患者总结（“交班”）中记录精神状态和精神状态变化的频率。
这是一项在 2 所教学医院进行的回顾性队列研究，纳入了 2009 年 3 月 16 日至 2010 年 3 月 15 日期间住院的一般内科患者。参与者包括有精神状态变化不良事件（MSAE）的患者及其提供者。通过病历回顾识别有 MSAE 的患者及其事件的详细信息。对交班记录进行精神状态记录的审查。主要观察指标为：（1）有 MSAE 的患者中，有精神状态记录在交班记录中的比例；（2）有 MSAE 的患者中，精神状态变化记录在交班记录中的比例。
共有 68 名患者发生 MSAE 并纳入样本。50%的 MSAE 归因于药物；75%的这些事件是由护士首次发现的。仅有 25%的 MSAE 患者的精神状态变化记录在交班记录中。
在书面交班中记录精神状态并不常见。尤其令人担忧的是，通过病历审查发现的 MSAE 患者很少有反映这些事件的交班记录。应设计干预措施以增加交班记录中记录这些信息。
