The Missing Record of Mental Status in Written Sign-Outs
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.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2019 |
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| Erschienen: |
2019 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:15 |
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| Enthalten in: |
Journal of patient safety - 15(2019), 4 vom: 16. Dez., Seite e40-e43 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Croix, Michael [VerfasserIn] |
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| Links: |
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| Themen: |
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| Anmerkungen: |
Date Completed 08.05.2020 Date Revised 08.05.2020 published: Print Citation Status MEDLINE |
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| doi: |
10.1097/PTS.0000000000000280 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| PPN (Katalog-ID): |
NLM268106606 |
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| 100 | 1 | |a Croix, Michael |e verfasserin |4 aut | |
| 245 | 1 | 4 | |a The Missing Record of Mental Status in Written Sign-Outs |
| 264 | 1 | |c 2019 | |
| 336 | |a Text |b txt |2 rdacontent | ||
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| 500 | |a Date Completed 08.05.2020 | ||
| 500 | |a Date Revised 08.05.2020 | ||
| 500 | |a published: Print | ||
| 500 | |a Citation Status MEDLINE | ||
| 520 | |a 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 | ||
| 520 | |a 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 | ||
| 520 | |a 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 | ||
| 520 | |a 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 | ||
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Research Support, Non-U.S. Gov't | |
| 700 | 1 | |a Miller, Donna |e verfasserin |4 aut | |
| 700 | 1 | |a Whittle, Jeff |e verfasserin |4 aut | |
| 700 | 1 | |a Singh, Siddhartha |e verfasserin |4 aut | |
| 700 | 1 | |a Schapira, Marilyn M |e verfasserin |4 aut | |
| 700 | 1 | |a Carnahan, Jennifer |e verfasserin |4 aut | |
| 700 | 1 | |a Kuester, Jessica |e verfasserin |4 aut | |
| 700 | 1 | |a Kallio, Christa |e verfasserin |4 aut | |
| 700 | 1 | |a Framberg, Susan |e verfasserin |4 aut | |
| 700 | 1 | |a Fletcher, Kathlyn E |e verfasserin |4 aut | |
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