The Language of Delirium: Keywords for Identifying Delirium from Medical Records
Department of Medicine, Division of Geriatric Medicine; Meyers Primary Care Institute
Aged; Aged, 80 and over; Cohort Studies; Delirium; *Electronic Health Records; Female; Humans; Male; *Terminology as Topic
Geriatric Nursing | Geriatrics | Health Information Technology | Mental Disorders
Electronic medical records (EMRs) offer the opportunity to streamline the search for patients with possible delirium. The purpose of the current study was to identify words and phrases commonly noted in charts of patients with delirium. The current study included 67 patients (nested within a cohort study of 300 patients) ages 70 and older undergoing major elective surgery with evidence of confusion in their medical charts. Eight keywords or phrases had positive predictive values of 60% to 100% for delirium. Keywords were charted more often in nursing notes than physician notes. A brief list of keywords may serve as a building block for a methodology to screen for possible delirium from charts, with particular attention to nursing notes, for research and real-time clinical decision making.
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Citation: J Gerontol Nurs. 2015 Aug;41(8):34-42. doi: 10.3928/00989134-20150723-01. Link to article on publisher's site
Journal of gerontological nursing
Puelle, Margaret R.; Kosar, Cyrus M.; Xu, Guoquan; Schmitt, Eva; Jones, Richard N.; Marcantonio, Edward R.; Cooper, Zara; Inouye, Sharon K.; and Saczynski, Jane S., "The Language of Delirium: Keywords for Identifying Delirium from Medical Records" (2015). University of Massachusetts Medical School Faculty Publications. 953.