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Michigan Adult Treatment Protocols ALTERED MENTAL STATUS Date: November 15, 2012-Page 1 of 1 Altered Mental Status The purpose of this protocol is to provide for the assessment and treatment of patients
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How to fill out altered mental status:

01
Begin by asking questions to gather information about the individual's background, medical history, and current symptoms. This can include asking about any recent illnesses, medications, substance use, or any significant life events.
02
Perform a thorough physical examination, paying attention to any noticeable changes or abnormalities in the individual's behavior, speech, or cognition. This may include assessing their level of consciousness, orientation, memory, reasoning, and attention span.
03
Use specific tools or assessment scales, such as the Glasgow Coma Scale or the Mini-Mental State Examination, to further evaluate the individual's cognitive functions and to quantify the extent of their altered mental status.
04
Document all the findings in a clear and concise manner, including relevant details such as the date and time of assessment, the individual's vital signs, pertinent medical history, and any interventions or treatments provided.
05
Communicate the findings and observations with members of the healthcare team involved in the individual's care, such as nurses, doctors, or psychiatrists. This collaboration can help in developing a comprehensive plan for further evaluation and management of the altered mental status.

Who needs altered mental status?

01
Individuals who exhibit signs of confusion, agitation, disorientation, or other changes in their mental state may require an assessment of their altered mental status.
02
Patients with acute or chronic medical conditions, such as infections, neurological disorders, drug overdose, metabolic abnormalities, or traumatic brain injuries, are often evaluated for altered mental status.
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Altered mental status can also be an important consideration in older adults with cognitive decline, patients with psychiatric disorders, or individuals who have undergone major surgeries or anesthesia.
Note: It is important to consult with a healthcare professional or follow institutional protocols when filling out altered mental status forms or assessing an individual's mental status. The information provided here is for illustrative purposes only and should not substitute for professional medical advice.
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Altered mental status refers to a change in a person's mental state, which can include confusion, disorientation, or other changes in cognition.
Healthcare professionals such as doctors, nurses, and mental health specialists are typically required to document and report altered mental status.
Altered mental status can be filled out by documenting the patient's symptoms, conducting a physical exam, and reviewing medical history.
The purpose of documenting altered mental status is to track changes in a person's mental health, aid in diagnosis, and guide treatment.
Information that must be reported includes the patient's symptoms, any relevant medical history, medications, and other factors that may be contributing to the altered mental state.
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