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Metabolic Encephalopathy

Documentation Tip of the Week: Dementia

Posted on Wed, Aug 19, 2015
Documentation Tip of the Week: Dementia

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

It is important when documenting dementia to state whether the mental status is consistent with the patient’s baseline or if it is an acute condition:
 

  • Acute Confusion or Acute Delirium on Chronic Dementia
  • Dementia with Behavioral Disturbance
  • Sundowning linked with Dementia
    • Are there changes in the patient’s mental status at night?
  • Metabolic Encephalopathy
    • Are the changes in mental status worsened by infection?
 
 
NO SOI LOW SOI HIGH SOI
Altered Mental Status Acute Delirium; Sundowning Metabolic or Toxic Encephalopathy

SOI= Severity of Illness



Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.

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