What should be included in a sample progress note for a patient undergoing ethanol (ETOH) withdrawal?

Sample Progress Note for ETOH Withdrawal Patient

A comprehensive progress note for a patient with alcohol withdrawal syndrome should include standardized assessment tools, vital signs monitoring, withdrawal symptom evaluation, and clear medication protocols to prevent progression to severe withdrawal complications.

Chief Complaint and History

• Document time of last alcohol consumption, as withdrawal symptoms typically develop within 6-24 hours after the last drink 1
• Record drinking pattern using standardized assessment tools like AUDIT or CAGE questionnaire 2
• Document quantity, frequency, and duration of alcohol use 2
• Note any previous withdrawal episodes, especially those with complications like seizures or delirium tremens 3

Assessment Tools

• Include CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised) score to quantify withdrawal severity - scores >8 indicate moderate AWS and ≥15 indicate severe AWS 1, 4
• Consider using shorter assessment tools like the Brief Alcohol Withdrawal Scale (BAWS) which has shown good correlation with CIWA-Ar (sensitivity 85.3%, specificity 65.8%) 5
• Document DSM-5 criteria met for Alcohol Use Disorder severity (mild: 2-3 criteria, moderate: 4-5 criteria, severe: ≥6 criteria) 2

Physical Examination

• Record vital signs with special attention to tachycardia, hypertension, and hyperthermia 1, 6
• Document presence and severity of tremors, sweating, agitation, and hyperreflexia 1
• Assess for signs of hallucinations, disorientation, or altered mental status 2
• Evaluate for signs of liver disease or other alcohol-related organ damage 2

Laboratory and Diagnostic Tests

• Document relevant laboratory findings including liver function tests, electrolytes, and CBC 2
• Consider biomarkers such as GGT, CDT, or other indicators of chronic alcohol use 2

Assessment

• Classify withdrawal severity (mild, moderate, severe) based on CIWA-Ar or other validated scale 1, 4
• Document risk factors for complicated withdrawal (history of seizures, delirium tremens, comorbid medical conditions) 3, 4
• Note presence of any withdrawal complications (seizures, hallucinations, delirium) 6

Treatment Plan

• For mild to moderate withdrawal (CIWA-Ar score 8-14): Implement symptom-triggered benzodiazepine protocol with diazepam 10 mg 3-4 times during first 24 hours, reducing to 5 mg 3-4 times daily as needed 7, 8
• For severe withdrawal (CIWA-Ar score ≥15): Consider fixed-schedule benzodiazepine dosing with close monitoring 8, 4
• Document supportive care measures including IV fluids, thiamine supplementation, and electrolyte replacement 3
• Include monitoring frequency (typically every 1-2 hours initially, then every 4-8 hours as symptoms improve) 8
• Note any adjunctive medications used (haloperidol for hallucinations only in combination with benzodiazepines) 8

Response to Treatment

• Document patient's response to interventions with updated CIWA-Ar scores 8, 4
• Note any adverse medication effects or complications 7
• Record changes in vital signs following treatment 6

Discharge Planning

• Include plan for continued outpatient management if appropriate 3
• Document referrals for alcohol use disorder treatment 2
• Note patient education provided regarding risks of continued alcohol use and importance of treatment 1
• Include follow-up arrangements and monitoring plan 3

Safety Considerations

• Document suicide risk assessment if indicated 7
• Note precautions taken to prevent falls or other injuries 7
• Include plan for managing potential withdrawal complications 6