What is the appropriate documentation for a patient's history of present illness with altered mental status?

History of Present Illness Documentation for Altered Mental Status

A comprehensive History of Present Illness (HPI) for a patient with altered mental status should document the onset, duration, progression, associated symptoms, and collateral information from informants, as this documentation is the cornerstone of diagnosis and management.

Essential Components of HPI Documentation

Chief Complaint

• Document the primary reason for presentation (e.g., "Altered mental status" or specific manifestation such as "confusion," "disorientation," "lethargy")

Onset and Timeline

• Document when symptoms began (sudden vs. gradual)
• Duration of symptoms (hours, days, weeks)
• Pattern of symptoms (fluctuating, persistent, worsening)
• Example: "Patient developed confusion 3 days ago that has been progressively worsening"

Specific Manifestations of Altered Mental Status

• Document specific cognitive changes observed:
  • Level of consciousness (alert, lethargic, somnolent, unresponsive)
  • Orientation status (person, place, time)
  • Attention deficits
  • Memory impairment (recent vs. remote)
  • Language difficulties
  • Behavioral changes (agitation, inappropriate behavior)
  • Hallucinations or delusions if present 1

Associated Symptoms

• Document presence or absence of:
  • Fever or recent infections
  • Headache
  • Seizure activity
  • Focal neurological deficits
  • Recent falls or head trauma
  • Changes in vision or speech
  • Urinary or bowel changes 2, 1

Collateral Information

• Document source of history (patient, family member, caregiver, EMS)
• Note any discrepancies between patient and informant reports
• Document baseline cognitive function and any pre-existing cognitive impairment
• Include specific examples of functional changes reported by informants 2

Relevant Medical History

• Document:
  • Prior episodes of altered mental status
  • History of dementia, stroke, seizures, or other neurological conditions
  • Recent medication changes or new prescriptions
  • Substance use history (alcohol, illicit drugs)
  • Recent surgeries or hospitalizations 1

Example Template

CHIEF COMPLAINT: [Specific presentation of altered mental status]

HISTORY OF PRESENT ILLNESS:
[Age]-year-old [gender] with [relevant past medical history] presenting with altered mental status that began [onset timing] and has been [progression pattern].

According to [source of history], the patient has been experiencing [specific cognitive/behavioral changes with examples]. The symptoms [are constant/fluctuate throughout the day] and are [better/worse] at [specific times].

Associated symptoms include [presence/absence of fever, headache, focal neurological symptoms, etc.]. Patient [has/has not] experienced similar episodes in the past.

Prior to this change, patient's baseline cognitive function was [description of baseline function and independence]. Recent changes in medications include [list changes or note none]. Recent illnesses or stressors include [list or note none].

The patient [does/does not] have a history of substance use, specifically [details if applicable].

Per [informant name/relationship], the patient has been experiencing difficulty with [specific examples of functional impairment] that was not present previously.

Important Documentation Considerations

1. Separate Patient and Informant Perspectives: The Alzheimer's Association guideline emphasizes that patient and informant perspectives may differ significantly, and both should be documented 2.

2. Document Specific Examples: Rather than just noting "memory problems," document specific examples provided (e.g., "unable to recall what he ate for breakfast," "got lost driving to familiar grocery store") 2.

3. Include Functional Impact: Document how the altered mental status has affected daily activities and independence 2, 1.

4. Note Awareness and Insight: Document the patient's level of awareness of their cognitive changes, as diminished insight is common in cognitive-behavioral impairments 2.

5. Document Vital Signs: Include documentation of vital signs at presentation, as abnormal vital signs may suggest specific etiologies 2, 1.

The American College of Radiology and other guidelines emphasize that thorough documentation of the history of present illness is essential for guiding appropriate diagnostic workup and management of altered mental status 2, 1.

Common Pitfalls to Avoid

• Failing to obtain collateral information when available
• Using vague terms like "confusion" without specific examples
• Omitting the timeline and progression of symptoms
• Not documenting baseline cognitive function
• Neglecting to note the presence or absence of key associated symptoms that might suggest specific etiologies 2, 1

By following this structured approach to documenting the history of present illness for patients with altered mental status, clinicians can ensure comprehensive assessment that facilitates appropriate diagnosis and management.