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Documenting dementia: baseline or acutely decompensated?

What to document when mental status changes

By Terryn Spragg, RN, CDIS, CCDS

Here’s some advice from our clinical documentation folks: If changes in your patient’s mental status are due to an acute systemic medical problem, such as a UTI, sepsis or adverse environmental reaction, etc., please consider documenting:

  1. Toxic encephalopathy (specify suspected agent responsible)
  2. Metabolic encephalopathy (specify suspected cause)
  3. Septic encephalopathy
  4. Acute hepatic encephalopathy

However, if a patient’s mental status is acutely decompensated, and due to their underlying dementia, please consider documenting:

  1. Dementia with behavioral disturbance
  2. Acute confusion on chronic dementia
  3. Acute delirium superimposed on dementia
  4. Sundowning linked with dementia

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