| RPT |
.| .| Confusion Assessment Method| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
and decrease in severity)?| <*Answer_7297*>| 5C. (If present or abnormal) Please describe this behavior.| <*Answer_7298*>| 6A. Did the patient demonstrate any memory problems during the
interview, such as inability to remember events in the hospital or difficulty remembering instructions?| <*Answer_6584*>| 6B. (If present or abnormal) Did this behavior fluctuate during the
interview (that is, tend | to come-and-go or increase and decrease in severity)?| <*Answer_7299*>| 6C. (If present or abnormal) Please describe this behavior.| <*Answer_7300*>| 7A. Did
the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or misinterpretations (for example, thinking something was moving when it was not)?| <*Answer_6585*>|
7B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend | to come-and-go or increase and decrease in severity)?| <*Answer_7301*>| 7C. (If present or
abnormal) Please describe this behavior.| <*Answer_7302*>| 8A. At any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness,
picking at bedclothes, tapping fingers, or making frequent, sudden changes in position? | <*Answer_6586*>| 8AB. (If present or abnormal) Did this behavior fluctuate during the interview (that
is, tend to come-and-go or increase and decrease in severity)?| <*Answer_7304*>| 8AC. (If present or abnormal) Please describe this behavior.| <*Answer_7305*>| 8BA. At any time during the
interview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly? |
<*Answer_6587*>| 8BB. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?| <*Answer_7306*>| 8BC. (If
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Is there evidence of an acute change in mental status from the
present or abnormal) Please describe this behavior.| <*Answer_7307*>| 9A. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with
insomnia at night?| <*Answer_7303*>| 9B. If yes, please describe the disturbance:| <*Answer_7308*>| | Copyright (c) 2003 Hospital Elder Life Program, LLC| | Information contained in
this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other
diagnostic activities and procedures.| $~
patient's baseline?| <*Answer_6577*>| 2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty keeping track of what was being said)?|
<*Answer_6578*>| 2B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?| <*Answer_6579*>| 2C.
(If present or abnormal) Please describe this behavior.| <*Answer_6580*>| 3A. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or
illogical flow of ideas, or unpredictable, switching from subject to subject?| <*Answer_6581*>| 3B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to
come-and-go or increase and decrease in severity)?| <*Answer_7295*>| 3C. (If present or abnormal) Please describe this behavior.| <*Answer_7296*>| 4. Overall, how would you rate this
patient's level of consciousness?| <*Answer_6582*>| 5A. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital,
using the wrong bed, or misjudging the time of day?| <*Answer_6583*>| 5B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend | to come-and-go or increase
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