Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Faculty of Medicine, 3710McMaster University, Hamilton, ON, Canada.
J Appl Gerontol. 2022 May;41(5):1485-1490. doi: 10.1177/07334648211067526. Epub 2022 Feb 17.
We assessed the accuracy of the ICD-10 code for delirium (F05) and its relationship with delirium discharge summary documentation.
We performed a retrospective chart review at three academic hospitals. The Chart-based Delirium Identification Instrument (CHART-DEL) was used to identify 108 hospitalized patients aged ≥65 years with delirium, and 758 patients without delirium as controls. We assessed the proportion of patients who received the F05 code and calculated the sensitivity and specificity. We compared the rates of F05 code received between patients with and without "delirium" documented in the discharge summary.
Among delirious patients, 46.3% received a F05 code, which has a sensitivity of 46.3% and specificity of 99.6% for delirium. Of charts with "delirium" in the discharge summary ( = 67), 67.2% were appropriately coded.
Current ICD-10 data inadequately capture delirium. Delirium documentation in the discharge summary is associated with improved delirium coding.
评估 ICD-10 谵妄（F05）编码的准确性及其与谵妄出院小结记录的关系。
我们在三所学术医院进行了回顾性病历审查。采用基于图表的谵妄识别工具（CHART-DEL）识别出 108 名年龄≥65 岁的患有谵妄的住院患者，以及 758 名作为对照的无谵妄患者。我们评估了接受 F05 编码的患者比例，并计算了敏感性和特异性。我们比较了出院小结中记录有“谵妄”和无“谵妄”的患者之间接受 F05 编码的比率。
在谵妄患者中，46.3%的患者接受了 F05 编码，其对谵妄的敏感性为 46.3%，特异性为 99.6%。在出院小结中有“谵妄”记录的病历中（=67），67.2%得到了适当编码。
目前的 ICD-10 数据不能充分捕捉谵妄。出院小结中的谵妄记录与改善谵妄编码相关。
