CIWA-AR RESULT

Date and time: [Date, 24-hour time]
Patient: [Name or ID, age]
Setting: [Emergency department, medical ward, withdrawal unit, or outpatient program]
Assessed by: [Name, credentials]

CONTEXT
Last drink: [Date and time; hours since]
Usual drinking: [Standard drinks a day, and for how long]
Breath alcohol: [Reading and time, or not done]
Past withdrawal: [Seizures, delirium, or hospital stays in past withdrawal, or none]
Other substances and medicines: [Benzodiazepines, other sedatives, opioids, beta-blockers, clonidine, or none]
Able to communicate: [Yes, with interpreter if used; or the reason not and the scale used instead]

VITAL SIGNS
Pulse: [Beats per minute]
Blood pressure: [Systolic/diastolic]
Temperature: [Degrees]
Breathing: [Respiratory rate, oxygen saturation]

SCORES
Nausea and vomiting: [0 to 7]
Tremor: [0 to 7]
Paroxysmal sweats: [0 to 7]
Anxiety: [0 to 7]
Agitation: [0 to 7]
Tactile disturbances: [0 to 7]
Auditory disturbances: [0 to 7]
Visual disturbances: [0 to 7]
Headache: [0 to 7]
Orientation: [0 to 4]
Total: [0 to 67]
Band: [Mild, moderate, or severe, by your protocol's ranges]
Previous total: [Time and score, or first assessment]

MEDICATION
Given under protocol: [Drug, dose, route, and time; or none, with the reason]
Thiamine: [Dose, route, and time]
Total in 24 hours: [Running total of the protocol drug]

REASSESSMENT AND ESCALATION
Next CIWA-Ar: [Time, and the interval the protocol sets]
Escalation triggers: [Score limit, seizure, hallucinations, confusion, vital sign limits]
Triggers met: [None, or which one, who was told, at what time, and the plan]