Cognitive Mental Status

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Trace DC63-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.COG_STATUS

Cognition vs baseline: oriented {level per baseline}, attention {consistent/inattentive}, fluctuation {none/present}, CAM {negative/positive}. Behavior/safety {status}. Skilled distinction of delirium vs baseline required daily. Supports Section C; cognitive goal {###}.

.COG_DELIRIUM

New delirium: acute change from baseline — {disorientation/lethargy/agitation}, fluctuating attention, disorganized thinking (CAM positive). Workup per order ({vitals/glucose/SpO₂/infection/med screen}); provider notified; representative notified; safety measures. Reassess; SCSA {y/n}. Supports Section C.

.COG_TRIGGER

Acute cognitive change with {fever/intake change/pain}. Screened for medical cause; provider notified; {workup ordered}; non-pharm measures; unnecessary psychotropic avoided. Reassess {when}. (Behavioral reference.)

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