Abstract
Proper documentation during neurology clinic visits is essential. Medical providers
that document precise and standardized findings aid other providers, nurses, and research
personnel. The American Academy of Neurology (AAN) created standardized quality measures
in order to improve delivery of care for patients with epilepsy, providers, and systems.
In this article, we reviewed a total of 777 charts in order to find documentation
on seizure frequency from the most recent clinical visit. Data was collected from
electronic healthcare records. During initial chart review, the following information
was noted: age, gender, seizure type(s), etiology type(s), provider (neurologist or
epileptologist), whether seizure frequency was noted, and the reason for no documentation.
The data review represented a sample of the epilepsy population seen at our institution.
Of the 734 individuals, 475 patients had seizure frequency documented (65%). Two hundred
and fifty-nine (259) people (35%) were missing seizure frequency data. For those individuals,
we determined the reasoning behind why this data was not present in the chart note.
Of those 259 charts, there were 65 (25%) charts missing seizure frequency, 161 (62%)
charts that were vague, and 33 (13%) charts where seizure frequency could not be determined.
Based on our findings, the documentation of seizure frequency is a gap in care.
Keywords
epilepsy - seizure - frequency - quality - measure
