Acute Confusion Documentation Suggestions
- Describe clinical signs and symptoms, noting changes from baseline (e.g., disorientation, paranoia, fearfulness, inappropriate behavior, etc.).
- Document work-up (e.g., urinalysis, CBC, WBC, blood culture, etc.).
- Document etiology, if known (e.g., UTI, hyperkalemia, pneumonia, etc.).
- Note any related comorbid conditions (e.g., acute depression, chronic depression, anxiety, etc.).
- Identify specific diagnosis (e.g., senile dementia, Alzheimer's disease, reactive confusion, etc.)
|Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: http://www.hce.org/medicare/mcareHPMP.html 7/7/03) |