| Delirium, which can be reversible and preventable, is one of the most significant complications affecting the hospitalized elderly today. The purpose of this descriptive retrospective chart review was to determine if medical records contain sufficient evidence to identify elderly patients who were at risk for developing delirium within 72 hours of hospital admission, and if accepted, evidence-based criteria were used to document the acute confusion. The chart's of 100 patients, at least 65 years of age, admitted to a rural hospital were reviewed retrospectively. The review indicated that there was sufficient evidence, based solely on the descriptors and clinical information, available in the medical record to make a diagnosis of delirium. The chart review revealed that sixteen of the subjects met full clinical criteria to receive a medical diagnosis of delirium, however only one patient was diagnosed by a physician as having delirium. |
