Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Assessment and Screening:
CAM-ICU Score: [Score] – Document the Confusion Assessment Method for the ICU score, a validated tool for delirium screening.
Onset: Indicate the suspected onset of delirium (acute vs. subacute).
Duration: Estimate the duration of delirium symptoms.
Severity: Describe the severity of delirium (hypoactive, hyperactive, mixed).
Clinical Findings:
Mental Status: Describe the patient’s level of alertness, orientation, and cognitive function. Mention any language or communication difficulties.
Psychomotor Findings: Note the presence of psychomotor agitation, psychomotor retardation, or a combination of both.
Sleep-wake Cycle: Describe any disturbances in sleep patterns, such as insomnia or daytime drowsiness.
Possible Precipitating Factors:
Underlying medical illness: List any potential medical conditions contributing to delirium (e.g., sepsis, pneumonia, electrolyte imbalances).
Medications: Enumerate current medications that could be contributing to delirium (e.g., sedatives, narcotics, corticosteroids).
Metabolic abnormalities: Mention any relevant electrolyte imbalances, dehydration, or hepatic/renal dysfunction.
Sensory Deprivation: Indicate if the patient is experiencing limited sensory input due to environment or sedation.
Pain/Discomfort: Note the presence of pain or discomfort that could be contributing to delirium.
Alcohol/Substance Withdrawal: Indicate if there is a history of alcohol or substance abuse and potential for withdrawal symptoms.
Treatment Plan:
Non-pharmacological interventions:
Addressable risk factors (e.g., correcting electrolyte imbalances, reducing unnecessary medications).
Environmental modifications (e.g., providing clocks, calendars, familiar objects).
Mobilization as tolerated.
Reorientation and cognitive stimulation.
Pain management.
Family presence and support.
Pharmacological interventions: If indicated, document the specific medication chosen for delirium management (e.g., low-dose atypical antipsychotics) and rationale for use.
Response to Treatment:
Describe any improvement or worsening of delirium symptoms since initiation of treatment.
Note any side effects from medications used for delirium management.
Prognosis:
Discuss the potential impact of delirium on ICU stay, hospital course, and long-term cognitive function.
Communication and Coordination:
Document communication with the patient’s family regarding delirium diagnosis and management plan.
Mention collaboration with other healthcare professionals involved in the patient’s care (e.g., psychiatry, neurology).
Plan for Follow-up:
Outline the frequency of delirium assessments using CAM-ICU or other tools.
Indicate the plan for monitoring response to treatment and potential adjustments.