Document cognition against the baseline and capture the MDS data:
The documented cognitive baseline and today’s status; orientation, attention, and any fluctuation over the shift (the hallmark of delirium).
Delirium screening (CAM features: acute onset/fluctuating course, inattention, disorganized thinking, altered consciousness) and BIMS-relevant status for the MDS.
Behavioral and safety implications (falls, wandering, resistance to care) and any acute trigger to screen for (infection, medication, hypoxia, glucose, pain, constipation).
MDS-supportive data
Cognition (BIMS) and signs/symptoms of delirium (CAM) are coded in MDS Section C, mood in Section D, and the diagnosis in Section I. The record must document the cognitive status, any delirium features, and the baseline comparison so Section C is supported.
