The management of geriatric syndromes forms a major component of modern clinical practice but our findings demonstrate poor capture of this information in both the discharge summary and hospital coding. The completeness of information for geriatric syndromes was significantly worse than for medical diagnoses and this suggests that the complexity of admissions for frail older people is not being reflected in coding data and that performance is likely to be underestimated.
The reasons are multiple14
. There is evidence that the current coding system based on the International Classification of Diseases 10 (ICD-10) system is inadequate for classifying complex co-morbidity and geriatric syndromes15,16,17
. The geriatric syndromes are generally ascribed ICD10 R-codes which are’ unattributable signs and symptoms’ and specific wording is required to describe the syndrome in order for a code to be ascribed. For example there is no ICD-10 code for intellectual deterioration. However confusion can be coded as unspecified dementia, delirium not induced by alcohol, disorientation not specified or as other dissociative disorders.
However the failure to record information on geriatric syndromes in the discharge summary suggests that education of hospital teams looking after frail older people is equally important. This may be a particular issue when discharge summaries are completed by non-specialist junior staff. There is evidence that the number of errors decrease with the seniority of the individual completing the summary17
. Poor hand writing may also be contributory. One study showed that of 117 notes, 18 sets (15%) had handwriting so illegible that the whole clinical history was unclear18
Several other studies have demonstrated systematic under-reporting of geriatric syndromes, for example one study showed that 38% of patient reported falls were not recorded on computerised accident and emergency records19
and it has been recently suggested that fall injury mortality is being underestimated20
. This finding is consistent with previous work demonstrating that two common geriatric syndromes, incontinence and pressure ulcers, were rarely recorded on discharge and therefore could not be ascertained from hospital administration databases21
. This is an area that is being actively addressed in the United States where the link between financial reimbursement and coding of hospital activity is now well established22
There were some limitations to this small descriptive study. The number of cases for several medical diagnoses was low. Nevertheless it was possible to see a significant difference between the overall capture of information on geriatric syndromes and medical diagnoses. In addition, the retrospective case note review could not provide a definitive explanation why information in the medical notes did not reach the discharge summary or hospital coding.
However our findings do suggest approaches that could be used to improve the recording of information on geriatric syndromes. We are piloting a problem list bookmark which is kept at the current page in the medical notes and updated as new problems are identified. This is then used to complete the discharge summary. Also local education programmes are underway both on the importance of capturing the complexity of the care provided and on how this can be achieved. Limitations in the current coding system with regard to the consistent classification of geriatric syndromes remain to be resolved.