title: Mental Status Documentation: Information Quality and Data Processes.
abstract: Delirium is a fluctuating disturbance of cognition and/or consciousness associated with poor outcomes. Caring for patients with delirium requires integration of disparate information across clinicians, settings and time. The goal of this project was to characterize the information processes involved in nurses' assessment, documentation, decisionmaking and communication regarding patients' mental status in the inpatient setting. VA nurse managers of medical wards (n=18) were systematically selected across the US. A semi-structured telephone interview focused on current assessment, documentation, and communication processes, as well as clinical and administrative decision-making was conducted, audio-recorded and transcribed. A thematic analytic approach was used. Five themes emerged: 1)Fuzzy Concepts,2)Grey Data,3)Process Variability4)Context is Criticaland 5)Goal Conflict.This project describes the vague and variable information processes related to delirium and mental status that undermine effective risk, prevention, identification, communication and mitigation of harm.
authors.affiliation: VA IDEAS Center of Innovation, SLC, UT; Department of Biomedical Informatics University of Utah School of Medicine, SLC UT.
authors.forename: Charlene
authors.initials: C
authors.lastname: Weir
authors.affiliation: Department of Biomedical Informatics University of Utah School of Medicine, SLC UT.
authors.forename: Bryan
authors.initials: B
authors.lastname: Gibson
authors.affiliation: VA IDEAS Center of Innovation, SLC, UT; Department of Biomedical Informatics University of Utah School of Medicine, SLC UT.
authors.forename: Teresa
authors.initials: T
authors.lastname: Taft
authors.affiliation: Department of Biomedical Informatics University of Utah School of Medicine, SLC UT.
authors.forename: Stacey
authors.initials: S
authors.lastname: Slager
authors.affiliation: VA IDEAS Center of Innovation, SLC, UT.
authors.forename: Lacey
authors.initials: L
authors.lastname: Lewis
authors.affiliation: Department of Biomedical Informatics University of Utah School of Medicine, SLC UT; Summit Health Informatics.
authors.forename: Nancy
authors.initials: N
authors.lastname: Staggers
mesh_terms: D003657:Decision Making; D003693:Delirium / Q000175:diagnosis* / Q000628:therapy; D004282:Documentation; D006801:Humans; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D009718:Nurse Administrators; D010346:Patient Care Management; D010348:Patient Care Team; D014481:United States