Abstracts

Rationale: Documentation of diagnosis in the electronic medical record (EMR) is discrete, by terminology in drop-down menus or codes selected from ICD-10. The code used for nonepileptic spell (NES) is R56.9. This same ICD-10 code also applies to multiple nonspecific seizure terms, creating potential confusion if only the number is entered into a data field. Patients who undergo definitive epilepsy monitoring unit (EMU) testing and are found to have only spells without electrographic correlate will have a prior diagnosis of "seizure" changed to "nonepileptic spell" as the discharge diagnosis, but the ICD-10 code remains the same. This coding problem as well as the uncorrected persistence of the prior wrong diagnosis in other places in the medical record, can result in misdiagnosis perseveration by referring physicians, and confusion by patients who have access to chart notes. This series identified a number of patients whose EMU-confirmed NES diagnosis, and subsequent treatment plan, reverted back to seizures because of persistent misinformation in the EMR. Methods: 100 adult patients between January 2014 and January 2016 who were discharged from the Wake Forest EMU with a sole diagnosis of NES and thus had no indication for long term antiepileptic drug (AED) therapy. The problem list for these patients was updated to remove "seizure" and replace with "nonepileptic spell". All were patients who were also seen in non-neurology Wake Forest clinics before the EMU, so could reasonably be expected to have followup notes to review after the EMU. All inpatient and outpatient notes were reviewed following the EMU to determine whether the patient was later characterized as having a diagnosis of "seizure" or "nonepileptic spell". Charts were also reviewed to determine if AED therapy was resumed or continued. Results: 19 patients were lost to followup, and 12 patients refused to accept the diagnosis of NES, and returned to their original physician who continued to prescribe AEDs. Of the remaining 69 patients, 32 had subsequent notes by a physician stating the patient had seizures. In 11 of these cases, the patient went to the ED for a NES and in 5 cases was treated with an IV AED and referred to Neurology clinic urgently. In 2 of these cases, the patient was admitted to the Neurology service for seizure "emergency". Both were referred for continuous video EEG monitoring for refractory "seizures" (again). It was one of these two cases that prompted this chart review. Conclusions: Use of EMRs has proven to have not only benefits, but challenges. This series demonstrates how the EMR increases the risk of retaining the incorrect diagnosis of epilepsy. Physicians commonly use "copy forward" and "cut and paste" within notes to save time, problem lists may be updatedfrom preceding notes rather than the current note, causing old diagnoses to populate. Diagnoses also may have been listed within history or as free text in fields can also be autopopulated in visit templates. Despite "undiagnosing" previously in the EMU, the apparent validation of " seizures" in the medical record by another physician may result in recurrent NES in an already suggestible patient. Resuming AEDs risks side effects and perpetuates belief in the incorrect diagnosis. Repeat epilepsy evaluations and admissions for an incorrect diagnosis use resources that could better serve patients who do have difficult to control epilepsy. Finally, the reversion to a seizure diagnosis means that the patient's true diagnosis, usually a conversion disorder, is not being treated, as the patient will not be seeing a therapist. Funding: NA