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Temporal changes in the documentation of neurological findings among patients with acute ischaemic stroke in a single centre in Japan: a retrospective cross-sectional study
  1. Junpei Komagamine1,
  2. Tomoko Komagamine2
  1. 1 Department of Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Tochigi, Japan
  2. 2 Department of Neurology, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
  1. Correspondence to Dr Junpei Komagamine; junpei0919{at}yahoo.co.jp

Abstract

Objective To evaluate temporal differences in the documentation of neurological findings by the same physicians in patients with ischaemic stroke while in hospital. We also investigated differences in the rate of documentation of neurological findings in patients with stroke between internists and neurosurgeons.

Design A retrospective medical chart review.

Participants Hospitalised adult patients with acute ischaemic stroke who stayed 7 or more days in our hospital. Neurosurgeons (n=8) and internists (n=19) caring for these patients (including up to 10 patients per physician).

Main outcome measures The documentation rate of any neurological finding in the patients on each day (from day 1 to 7 and on discharge). The documentation rates of eight neurological finding components (consciousness, mental status, cranial nerves, motor function, sensory function, coordination, reflexes and gait). We included only documentation by the same physician. Fisher’s exact test was used to evaluate differences in outcomes between neurosurgeons and internists.

Results During the study period, we identified 172 patients with stroke who were cared for by 27 physicians. The documentation rates of any neurological findings were 94% (day 1), 58% (day 2), 35% (day 3), 40% (day 4), 32% (day 5), 30% (day 6) and 23% (day 7). On discharge, all eight neurological finding components were documented in less than 10% of all cases. The documentation rate was significantly higher by internists than that by neurosurgeons on each day but not on discharge.

Conclusions The documentation rate of neurological findings by physicians during usual stroke care decreased to less than 50% after the third hospital day. Given the importance of temporal changes in the neurological symptoms of patients with stroke, further study is needed to determine whether this low documentation rate after the third hospital day was due to a lack of physician interest in neurological findings or other factors.

  • neurology
  • stroke
  • adult neurology

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Footnotes

  • Contributors JK conceived the project. Both authors wrote the protocol for this study. JK collected and analysed the data. Both authors interpreted the results and wrote the manuscript. Both authors gave final approval for the submission of this revised version for consideration for publication.

  • Competing interests None declared.

  • Ethics approval This study was approved by the Medical Ethical Committee of National Hospital Organization Tochigi Medical Center (protocol No. 29-14) and was performed in accordance with the Declaration of Helsinki. This study was also conducted in accordance with the Ethical Guidelines for Epidemiological Research in Japan. We were not required to obtain individual informed consent because we used de-identified data obtained from medical records and did not contact the patients. According to Japanese Ethical Guidelines, we did display a poster in the waiting room of the hospital to provide information about the collection and use of data for this study and the protection of personal information.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data sharing is not applicable because we did not receive informed consent for data sharing from the participants. The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

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