No baseline comparison, no delirium features, no trigger screen — misses that new confusion may be a treatable acute illness.
The new-delirium model note in §4: the acute change versus the baseline, the CAM features, the workup and trigger screen, notification, and safety measures.
“A&O×2 per baseline.”
For an at-risk resident, no attention/fluctuation assessment.
“Oriented to self/place per baseline, attention consistent with baseline across the shift, no acute fluctuation (CAM negative).”
“Pleasantly confused.”
Dismissive; obscures whether a change occurred.
Document the objective cognitive status against the baseline and whether any acute change is present.
