The Missing Record of Mental Status in Written Sign-Outs. J Patient Saf 2019 Dec;15(4):e40-e43
Date
01/19/2017Pubmed ID
28098585DOI
10.1097/PTS.0000000000000280Scopus ID
2-s2.0-85009775317 (requires institutional sign-in at Scopus site)Abstract
OBJECTIVE: 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.
PATIENTS AND METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.
Author List
Croix M, Miller D, Whittle J, Singh S, Schapira MM, Carnahan J, Kuester J, Kallio C, Framberg S, Fletcher KEAuthors
Kathlyn E. Fletcher MD Professor in the Medicine department at Medical College of WisconsinJeffrey Whittle MD Professor in the Medicine department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AgedAged, 80 and over
Communication
Continuity of Patient Care
Delirium
Documentation
Drug-Related Side Effects and Adverse Reactions
Female
Health Status
Hospitalization
Humans
Male
Medical Records
Mental Health
Middle Aged
Physicians
Retrospective Studies
Writing
