From the Guidelines
The recommended format for documenting delirium in patient notes should follow a structured approach, including the use of standardized assessment tools like the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC), as suggested by the 2022 guidelines 1. When documenting delirium, clinicians should first clearly state the presence or absence of delirium, followed by specific observations supporting the diagnosis.
- Include the time of onset, precipitating factors, and fluctuations in symptoms throughout the day, as delirium typically develops rapidly over hours to days and can fluctuate in severity 1.
- Document specific examples of the patient's cognitive deficits, such as inability to maintain attention during conversation or follow commands, which are key features of delirium 1.
- Note the patient's level of consciousness (hyperactive, hypoactive, or mixed delirium) and any hallucinations, delusions, or agitation observed, as these are critical components of the delirium diagnosis 1.
- Include vital signs, laboratory values, and medication review that may contribute to or explain the delirium, as certain medications and medical conditions can precipitate delirium 1.
- Document the delirium severity using a validated scale if available, such as the Delirium Rating Scale-Revised-98 (DRS-R-98) or the Memorial Delirium Assessment Scale (MDAS), to track the course of delirium and evaluate the effectiveness of interventions. Finally, include the management plan with both non-pharmacological interventions (reorientation strategies, sleep hygiene, sensory aids) and any pharmacological treatments if necessary, such as the use of i.v. haloperidol or droperidol in hyperactive or hypoactive delirium 1. Thorough documentation is essential for continuity of care, tracking the course of delirium, and evaluating the effectiveness of interventions.
From the Research
Documenting Delirium in Patient Notes
To describe delirium in patient notes, it is essential to include the key features of the condition. Delirium is characterized by:
- Fluctuations in attention and awareness 2
- Prominent inattentiveness with other cognitive deficits 2
- A change in awareness and visual hallucinations 2
- Disturbances in consciousness, affecting both its content (i.e., attention) and level (i.e., arousal) 3
Recommended Format for Documenting Delirium
When documenting delirium in patient notes, consider the following:
- Use a systematic approach to evaluate the patient's condition, including the frequency and impact of possible causes 4
- Distinguish symptoms from other cerebral alterations, such as preexisting dementia or depression 4
- Include information on the patient's level of attention, awareness, and any visual hallucinations 2
- Note any fluctuations in the patient's condition, as delirium is characterized by acute and transient brain dysfunction 3
Assessment and Diagnosis
Delirium is a clinical diagnosis that requires a thorough history and clinical examination 2. The use of well-validated delirium screening tools, such as the 3-Minute Diagnostic Assessment, 4 A's Test, and proxy-based measures, can aid in diagnosis and monitoring response to treatment 5. The Confusion Assessment Method-Severity Score can also be used to assess the severity of delirium and aid in risk stratification and prognosis 5.
Treatment and Management
Treatment of delirium involves identifying and addressing potentially modifiable risk factors, such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation 3, 5. Nonpharmacologic approaches, including the "ABCDEF bundle," have been shown to be effective in reducing delirium 3. Pharmacologic treatment with antipsychotics may be considered in severe cases, but its use is not supported by findings from placebo-controlled trials 3, 5.