ABSTRACT
Delirium, a life-threatening complication for hospitalized older adults associated with adverse outcomes, is often underrecognized and underreported. The purpose of the current study was to analyze delirium documentation for hospitalized older adults. Charts of 34 patients, aged 71 and older with documented delirium and referral to a Hospital Elder Life Program, were reviewed. With the exception of International Classification of Diseases-9 coding, delirium was only mentioned in 12 (35.3%) charts, although descriptors potentially indicative of delirium were usually recorded. Of these, the most frequently recorded were confusion (94.1%), mental status change (70.6%), and disorientation (61.8%). When nurses charted delirium descriptors, only 5.9% of their notes included physician referral. Physician responses were to order diagnostic tests and medications, usually antipsychotic or benzodiazepine agents. Of 28 patients requiring transfer to another facility after discharge, delirium was mentioned in only one transfer note. Commonly used delirium descriptors can be used for the development of natural language processing tools for clinical decision support. [Journal of Gerontological Nursing, 43(3), 32-40.].
