Altered Mental Status

agiuliagiuli
in CDI Talk Archive
The physicians are improving in providing a rationale for altered mental status, but I wanted opinions on whether you would query for further information if you saw the following note:
ALTERED MENTAL STATUS MOST LIKELY DUE TO INFECTION, PRIOR MORPHINE: IMPROVING

I thank you in advance for your opinion.

Comments

  • dvitalone1dvitalone1
    edited May 2016
    Definitely would query for encephalopathy!




  • robert.hodges2robert.hodges2
    edited May 2016
    Severe sepsis may also be an issue. I would query.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens


  • lauriehigginslauriehiggins
    I would query for encephalopathy but not sure if it would be metabolic or toxic
    since the doc is saying "due to infection, prior morphine."
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