Tips on documenting AMS

AMS is a term with many potential clinical meanings, but is considered “confusion” when the patient’s medical record is coded.

To ensure the complexity of care rendered is accurately reported, please consider using the following definitions, when appropriate, rather than the term “altered mental status”.

  • Encephalopathy – Nondegenerative diffuse brain disorder secondary to an underlying process, eg. sepsis, toxic, metabolic, hypertensive, hepatic, anoxic. The hallmark is altered mental state.
  • Delirium – Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Disorganized thinking, agitation, misperceptions of sensory stimuli, and visual hallucinations.
  • Dementia – Progressive decline in mental processes. Memory impairment , cognitive disturbances, and a disturbance in executive function.
  • Stupor – State of baseline unresponsiveness that requires repeated application of vigorous stimuli to achieve arousal.
  • Coma – State of unresponsiveness in which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation.
  • TIA – Brief cerebral, spinal, or retinal ischemia without acute infarction. Cerebral Embolus or Thrombus (without infarction) is usually an underlying cause of TIA.
  • Stroke – Neurological Symptoms with evidence of stroke on neuroimaging
  • Aborted Stroke – “Stroke in Evolution” – Transient neurologic symptoms due to ischemia with a normal MRI. Therapeutic efforts (e.g. tPA) may play a role.
  • Psychosis –Disturbance in perception of reality. Delusions, hallucinations, and thought disorganization.

Remember

The diagnoses for inpatients can be written as “possible”, “probable”, “suspected”, “likely” or “rule out”