Delirium Evaluation Note (Acute Mental Status Change)

Date/Time: [Current date and time]
Setting: [ED / floor / ICU / stepdown / PACU / other]
Evaluation Type: [Initial Delirium Evaluation / Interval Reassessment]
Reason for Evaluation: [Clinical trigger as reported by frontline staff]

Chief Concern

[Clinical trigger and acute mental status change observed] (One to two sentences stating the reason for evaluation and the nature of the acute change.)

Clinical Summary

[Age/sex, baseline cognitive status, key comorbidities, reason for admission, and time course of change] (One concise sentence.)

History

Baseline Status

• Cognition/Communication: [Baseline cognitive status, typical orientation, communication abilities]
• Behavior/Sleep: [Typical baseline behavior and sleep pattern]
• Function/Sensory: [Baseline mobility, ADLs, sensory aids used]
• Decision-making Capacity: [Baseline capacity status]
• Source of Baseline Information: [Source name and relationship] (If baseline cannot be obtained, document attempts made and best available proxy information. Do not infer baseline from current exam.)

Current Change

• Onset/Time Course: [Onset, last known normal, hours vs days]
• Fluctuation Pattern: [Better/worse times, relation to procedures/medications, sundowning]
• Key Delirium Features:
  • Attention: [Specific observed inattention examples]
  • Arousal Level: [alert / lethargic / stuporous / hypervigilant]
  • Thinking: [organized / disorganized / tangential]
  • Perceptual Disturbances: [hallucinations / illusions / none]
  • Sleep-Wake: [normal / reversed / fragmented]
  • Psychomotor Subtype: [hyperactive / hypoactive / mixed]

Precipitating Factors Reviewed

(Document presence, absence, or unknown for each category.)

• Physiologic: [hypoxia / hypotension / fever / glucose abnormality / electrolyte derangement / renal dysfunction / hepatic dysfunction]
• Infectious/Inflammatory: [suspected source present / absent / unknown]
• Neurologic: [stroke or TIA symptoms / seizure or post-ictal / head trauma / meningismus]
• Unmet Needs: [pain / urinary retention / constipation / hunger / thirst]
• Iatrogenic/Environmental: [recent surgery or anesthesia / transfers or room changes / sleep disruption / immobilization / tethers]
• Substance Withdrawal/Intoxication: [alcohol / benzodiazepines / opioids / other] (Specify last use if known.)

Medication Review

• Recent Changes: [New starts, dose escalations, increased PRN use, missed chronic medications]
• High-risk Classes Screen: [Anticholinergics, benzodiazepines or sedative-hypnotics, opioids, antipsychotics, corticosteroids, H2 blockers] (Note status and action for relevant agents.)
• Polypharmacy/Dosing: [Duplications, total count, renal/hepatic dosing concerns]
• History Limitations: [Source limitations] (Include only if medication history incomplete.)

Pertinent History

(Omit section if none relevant.)

• [Prior delirium episodes and known triggers]
• [Dementia subtype, especially Lewy body or Parkinson disease dementia]
• [Psychiatric history]
• [Seizure disorder]
• [Substance use history]

Examination

Vital Signs

[Current vital signs including BP, HR, RR, Temp, SpO2 with oxygen requirement; relevant trends such as fever curve; point-of-care glucose if obtained]

Physical Exam

• General: [Appearance, hydration, withdrawal/intoxication signs]
• HEENT: [Trauma signs, pupillary findings]
• Cardiopulmonary: [Oxygenation, breath sounds, perfusion]
• Abdomen/GU: [Tenderness, distention, bladder status]
• Skin: [Infection signs, pressure injury risk]
• Neurologic: [Focal deficits, tremor, asterixis]

Mental Status Examination

• Arousal: [alert / lethargic / stuporous / hypervigilant]
• Orientation: [Domains assessed and responses]
• Attention Testing: [Task used and performance] (Document at least one specific task: days/months backward, digit span, or serial subtraction.)
• Thought Process/Content: [Organization, paranoia, hallucinations] (Include brief quotes only if clarifying psychotic symptoms.)
• Communication Barriers: [hearing / vision / language / intubation / none]

Delirium Assessment Tool

• Tool Used: [4AT / CAM-ICU / ICDSC / other] (Use 4AT for general wards; CAM-ICU or ICDSC for ICU/ventilated patients.)
• Score/Result: [Numeric score or result]
• Interpretation: [positive / negative / equivocal]
• If Unable to Complete: [Barrier and plan to reassess] (Include only if applicable.)

Data Reviewed

• Key Labs: [CBC, metabolic panel, renal/hepatic function, glucose, UA and culture status, lactate, toxicology or drug levels] (Include results for labs obtained.)
• Studies: [ECG with QTc, chest imaging, neuroimaging] (Include results for studies performed.)
• Pending: [Pending labs/studies]
• Iatrogenic Burden: [Foley, restraints, central lines, ventilator, oxygen requirement]

Assessment

Delirium Status

[Delirium present / Delirium suspected (high likelihood) / Delirium not present / Unable to assess], [hyperactive / hypoactive / mixed] subtype, [superimposed on dementia / no baseline dementia]. (If not present, specify alternative diagnosis and whether patient remains at risk. If unable to assess, state barrier and mitigation plan.)

Contributing Factors

(Prioritize dangerous and reversible causes first. For each, note supporting evidence and planned intervention.)

• [Etiology, supporting evidence, planned intervention]
• [Additional contributors as applicable]

Differential Considerations

[Key alternatives considered and reasoning] (Address relevant differentials such as dementia progression vs delirium, depression/catatonia, primary psychosis, aphasia, nonconvulsive seizure, stroke, or medication adverse effect.)

Capacity Implications

(Include if delirium affects decision-making.)

[Capacity assessment status, surrogate decision-maker if needed, specific safety concerns]

Plan

Immediate Stabilization

(Omit section if patient hemodynamically stable.)

• [Airway/breathing/circulation interventions]
• [Oxygenation targets]
• [Glucose correction]
• [Escalation criteria]

Diagnostic Workup

(Document only tests being ordered with brief justification.)

• Metabolic: [Tests and rationale]
• Infectious: [Tests and rationale]
• Toxicologic: [Tests and rationale]
• Neurologic: [Tests and rationale]

Treatment of Underlying Causes

• [Intervention tied to specific etiology]
• [Additional targeted treatments]

Nonpharmacologic Interventions

• [Orientation aids: clock, calendar, familiar objects]
• [Sensory optimization: glasses, hearing aids]
• [Sleep protection measures]
• [Early mobility plan and PT/OT involvement]
• [Hydration/nutrition support]
• [Minimize tethers: discontinue unnecessary lines/Foley]
• [Family/caregiver engagement]

Medication Optimization

• Discontinue/Hold/Substitute: [Deliriogenic medications and rationale]
• Analgesia Strategy: [Agents and approach balancing pain control with sedation risk]
• Regimen Simplification: [Dose adjustments for renal/hepatic function]

Pharmacologic Treatment for Agitation

(Include only when nonpharmacologic strategies insufficient AND patient poses imminent risk to self/others or cannot receive essential care.)

• Target Symptom: [Specific behavior interfering with safety or care]
• Non-drug Strategies Attempted: [Strategies tried and why insufficient]
• Agent Selected: [Medication, dose, route] (Use lowest effective dose; screen for Parkinsonism/Lewy body contraindication.)
• Monitoring Plan: [Sedation level, vitals, QTc if relevant]
• Stop Criteria: [Explicit criteria and reassessment timeframe]

Safety Measures

• [Fall precautions with level of assistance]
• [Line/device safety measures]
• [Aspiration precautions and diet order]
• [Wandering/elopement precautions] (If applicable.)
• [De-escalation plan for agitation]

Restraint Documentation

(Omit section if restraints not used. Default stance is restraint avoidance.)

• Behavior Necessitating Restraint: [Specific unsafe behavior]
• Alternatives Attempted: [Less restrictive interventions tried]
• Restraint Type: [Type applied]
• Monitoring Plan: [Frequency and parameters]
• Discontinuation Criteria: [Specific criteria for removal]

Follow-up and Reassessment

• Reassessment Schedule: [Daily on wards; each shift in ICU]
• Urgent Reassessment Triggers: [New focal deficit, fever, hypoxia, persistent unresponsiveness, refractory agitation]
• Handoff Summary: [Baseline vs current, suspected causes, key medication changes, safety plan, pending studies]

Transition Planning

(Include when discharge or transfer approaching.)

• Delirium Status: [resolved / persistent]
• Medication Changes: [Changes with reasons and intended duration]
• Follow-up: [Plan for cognitive reassessment]
• Risk Reduction: [Post-discharge strategies and caregiver guidance]