CDI: Documenting Altered Mental Status


Many a coder has run across the diagnosis "altered mental status" on a patient chart and then scratched their head.   How do I code that?   It is all about the documentation.

Documenting altered mental status:

Physicians should indicate the chronicity and nature of the patient's alteration of mental status on the progress note as soon as possible after admission:


  • Acute
  • Chronic
  • Acute on Chronic
  • Other ________________
  • Unable to determine


  • Dementia
  • Delirium
  • Psychosis
  • Obtundation
  • Stupor
  • Coma
  • Other
  • Unable to determine

Please always  indicate the underlying cause of the altered mental status present on admission.

  • Encephalopathy
  • Alzheimer's disease
  • Acute stroke
  • Late effect of stroke
  • Transient ischemic attack
  • Seizure disorder
  • Other: ________________
  • Unable to determine


About the Author

Laura Legg


Laura Legg, RHIT, CCS, CDIP, AHIMA Approved ICD-10 CM/PCS Trainer, has over 30 years of health information management experience working with acute care hospitals, critical access hospital, and home services.  Laura has worked closely with HRG's HIM department and many healthcare providers nationwide.


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