Appendix.

Delirium Prediction Rule: chart abstraction tool terms and location

Risk Factor	Abstraction Terms	Abstraction Location(s)
Cognitive Impairment
Scoring: Positive if one of these terms is present	Dementia	H&P-HPI; H&P-PMH; PL
	Alzheimer’s Disease	H&P-HPI; H&P-PMH; PL
	Poor Historian	H&P-HPI; H&P-PMH; H&P-PE; NIA
	Memory loss	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Unarousable	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Uncooperative	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Demented	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Delirium	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Change in Mental Status	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Confused	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Encephalopathic	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Disoriented	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Lethargic	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Obtunded	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Stuporous	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Combative	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
	Altered Mental Status	H&P-CC; H&P-HPI; H&P-PMH; H&P-PE; NIA
Sensory Impairment
Scoring: Positive if one of these terms is present	Visual Loss	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Blindness	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Wears glasses	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Hearing impairment	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Hard of hearing	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Wears hearing aids	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
	Presbycussis	H&P-HPI; H&P-PMH; H&P-PE; NIA; PL
Dehydration
Scoring: Positive if BUN/Cr ≥ 18	Blood Urea Nitrogen	Adm-LV; H&P-LV
	Creatinine	Adm-LV; H&P-LV
Severe illness
Scoring: Positive if 2 of these terms	Age >60	Adm – cover sheet; H&P-HPI; NIA
	Metastatic Cancer	H&P-HPI; H&P-PMH; PL
	Lymphoma	H&P-HPI; H&P-PMH; PL
	Leukemia	H&P-HPI; H&P-PMH; PL
	AIDS	H&P-HPI; H&P-PMH; PL
	RR >25/min	H&P-PE; Adm - VS
	Systolic blood pressure <100 mmHg	H&P-PE; Adm - VS
	Pulse >120/min	H&P-PE; Adm - VS
	Creatinine >2.0 mg/dL	Adm-LV; H&P-LV
	Albumin <2.5 g/dL	Adm-LV; H&P-LV
	Total Bilirubin >2.9 mg/dL	Adm-LV; H&P-LV

Adm – admission; BUN – blood urea nitrogen; CC – chief complaint; Cr – creatinine; H&P – history and physical; HPI – history of present illness; LV – laboratory values; NIA – nursing intake assessment; PMH – Past Medical History; PE – physical exam; PL – Problem List; VS – vital signs