Cerebral Palsy, Depressive and Altered Mental Status

Cerebral Palsy

             

                                                          Cerebral Palsy

 

• Document presence of spasticity
• Document type:
    --Quadriplegic, Diplegic, Hemiplegic, etc.
    --Ataxic
    --Athetoid
    --Choreathetoid
    --Dyskinetic
    --Dystonic
    --Mixed
    --Syphilitic
• Document any associated diagnoses/conditions

Depressive

• Document episode:
    --Single
    --Recurrent
• Document severity:
    --Mild
    --Moderate
    --Severe
    --With psychotic features
    --Without psychotic features
• In partial or full remission (if applicable)
• Document any associated diagnoses/conditions

Altered Mental Status

Document the etiology of the altered mental status as:
    --Coma
    --Confusion/delirium (including drug-induced)
    --Drowsiness/somnolence
    --Stupor/semi-coma
    --Transient alteration of awareness
    --Encephalopathy
    --Alcoholic
    --Anoxic/hypoxic
    --Drug-induced/toxic (specify drug)
    --Hepatic
    --Hypertensive
    --Hypoglycemic
    --Metabolic/septic
    --Traumatic/post-concussion
    --Wernicke
    --Other (specify)
• Document any associated diagnoses/conditions