[Comparison of MDS-AC registration and conventional medical records in Iceland and other Nordic countries. A part of a Nordic study].
OBJECTIVE
Complex functional decline and comorbid state is an important indicator of outcome for hospital care of older adults. In today acute care it is important to quickly be able to target those who might benefit from geriatric assessment. The MDS-AC is an evaluation system for geriatric acute care patients that records functional impairment and co-morbid states. The object of this study was to compare the MDS-AC registration with the traditional nurses and doctors records for chosen variables important to older patient care in Iceland and other Nordic countries.


METHODS
This was a randomised prospective Nordic study. The study took place in Reykjavík, Copenhagen, Umeå, Oslo and Helsinki. Participants in each country were chosen from 75 year old and older patients admitted to acute care medical wards, 160 patients from each country. The results presented here show data from selected variables collected with the MDS-AC instrument version 1,1 in the first 24 hours of admission, compared with hospital notes for the first 48 hours.


RESULTS
For ADL and IADL impairments the medical record missed between 20 to 96% of items registered with the MDS-AC and between 33 to 100% when there is no impairment detected. This was true for all the participating Nordic countries but the Icelandic medical records were in comparison more often incomplete for the variables chosen.


CONCLUSIONS
The MDS-AC documents better than traditional medical records several important variables relating to function among the elderly. It may be possible to improve documentation with a standardized instrument such as the MDS-AC.
Samúelsson
Olafur
O
Department of Geriatrics, Iceland University Hospital, Landakoti, 101 Reykjavík.
Bjartmarz
Sigrún
S
Jensdóttir
Anna Birna
AB
Jónsson
Pálmi V
PV
D000203:Activities of Daily Living; D000368:Aged; D015897:Comorbidity; D003718:Denmark; D005387:Finland; D005568:Forms and Records Control; D015577:Geriatric Assessment; D006801:Humans; D007055:Iceland; D008499:Medical Records / Q000592:standards / Q000706:statistics & numerical data; D016347:Medical Records Systems, Computerized; D009664:Norway; D009737:Nursing Records / Q000592:standards / Q000706:statistics & numerical data; D010343:Patient Admission / Q000592:standards*; D011446:Prospective Studies; D013548:Sweden