No baseline vs acute-change distinction — misses a delirium that may be a treatable illness.
The delirium-on-dementia model note in §4: the acute change versus the baseline, the CAM, the medical-cause workup, and the non-pharmacologic measures.
“Agitated, given [PRN].”
Reflexive medication with no trigger screen or non-pharmacologic plan.
The BPSD model note in §4: the trigger screen (pain/infection/environment), the non-pharmacologic plan, and any psychotropic justified/monitored.
“Wanders.”
No safety plan or escalation.
Document the wandering/elopement safety plan and any near-elopement escalation.
