Table 2.

Selected Quotations from Delirium Positive Charts

Patient #	Quote†	Note Source
1	Lethargic, disoriented at times to place/time. Patient removed IV access while confused.	Nurse
	A+Ox3 @ start of this shift, though with frequent period of confusion. Patient bed alarmed for sedative and fall precaution.	Nurse
	A+Ox3. When asked questions, answered appropriately. Confused at times. Thought there was a shopping mall in the hospital.	Nurse
2	Around 3pm, pt was found to be unresponsive, disoriented. Unable to answer questions or follow commands.	Nurse
	Per reports, patient was at his baseline mental status this morning, but became more confused over the course of the day…At that time, patient was unable to keep his eyes open for more than 10 seconds at a time. Altered mental status.	ICU physician admission note
3	Mental status has been waxing and waning today. She is confused again, speaking nonsense, states she does not remember anything. Neuro: A+Ox3, answering questions appropriately, follows some commands.	Attending Physician
4	No major changes, pt continues to be somnolent, easily arousable, but then falls back asleep. Pt able to state name, date, hospital, and reason for her admission.	Nurse
	A&Ox3 in AM, by PM, confused and disoriented, team aware. 2pm, pt in bed and resting, very somnolent and tachy in the 140s. Pt not A&Ox3, garbled speech.	Nurse
5	Very somnolent and confused this morning. Unable to assess due to mental status. Patient very somnolent and confused. Unable to maintain conversation, drifts to sleep.	Acute pain service physician note
	Narcotic medication held to see if this helps confusion. Confusion clearing up, but not 100%. Unable to tell the date/year	Nurse
6	Patient initially impulsive, but mostly clear mentation early. Rapidly became profoundly delirious despite seroquel, haldol, Ativan with limited effect. Required vigilant observation. Bed alarm and frequent intervention.	Nurse
	This morning patient oriented to self/time plus hallucinations. Speech garbled. Patient confused but cooperative. Increasing clarity, increasing wakefulness, but appropriate. A+Ox3 this afternoon and after 4pm.	Nurse
7	Patient medicated with Ambien 2.5 mg po for sleep – awake at 5AM--confused, A+Ox1, urinated on floor, assisted to bed, alarm on for safety. Reoriented to surroundings.	Nurse
8	Event: confusion. Patient with increasing confusion this shift. At 9:30 pm she became more confused, yelling out, paranoid. Attempted to dial 911, telling nurse she is “scared, this isn’t a safe place”. Unable to reorient.	Nurse
9	Patient went to sleep 12:15am. ~ 3 am. Found sitting up on the bedside chair without any clothes on her. States: “I don’t know how I got here.” Assisted back to bed with maximal assist of 2.	Nurse
10	Acute change in conscious state – HCT 26.6 (decreasing 32.9) Into pt’s room @ 0630 to give PO Tyl. Pt confused, unaware of time/place. Acute change in mental status – overnight when woken a+ox3. Doesn’t remember surgeon, name of surgery, etc. Able to name DOB & spell last name. – no BUE weakness, speech clear, but kept saying “I don’t know, I’m confused”.	Nurse

^†A+O=alert and oriented; PACU=Postoperative acute care unit; ICU = Intensive Care Unit; A+O = Alert and Oriented; IV = intravenous; HCT = hematocrit; DOB = date of birth; BUE = bilateral upper extremity; PO = by mouth. Quotes are excerpts and do not necessarily represent all evidence of delirium in a patient’s chart. Quotes were edited to correct typographical errors; and 1 quote was paraphrased to protect identity.