How are medical records used in the diagnosis of delirium?

Updated: Apr 25, 2019
  • Author: Kannayiram Alagiakrishnan, MD, MBBS, MPH, MHA; Chief Editor: Glen L Xiong, MD  more...
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Answer

Gaps in the medical record such as once daily cognitive assessment or no formal assessments on the hallmarks of delirium (attention span and fluctuation) may make diagnosing the condition more difficult.  The physicians depend on health records (nursing notes) to identify a fluctuating course. The type of information might also be less than adequate for developing a timely diagnosis. So the recognition of delirium can be delayed by infrequent observation or documentation. [27]


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