CIWA-Ar Alcohol Withdrawal Assessment Log

Inspection template for scoring the 10-item CIWA-Ar alcohol withdrawal scale, documenting repeat assessments at protocol intervals, and recording medication response and escalation actions.

Assessment Context and Timing

• Assessment type documented
  Identify whether this is an initial CIWA-Ar assessment or a repeat assessment.
• Assessment date and time recorded
  Document the exact date and time the CIWA-Ar was completed.
• Protocol interval met for repeat assessment
  Confirm the reassessment occurred at the ordered protocol interval.
• Patient identity verified
  Confirm patient identity using two identifiers per facility policy.
• Assessment conditions appropriate
  Patient was awake enough to participate and assessment was completed in a suitable setting with minimal interruption.

CIWA-Ar Item Scoring

• Nausea and vomiting
  Score severity of nausea and vomiting.
• Tremor
  Score visible tremor with arms extended.
• Paroxysmal sweats
  Score sweating severity observed or reported.
• Anxiety
  Score anxiety level reported by the patient and observed by staff.
• Agitation
  Score restlessness and agitation.
• Tactile disturbances
  Score sensations such as itching, pins and needles, burning, or formication.
• Auditory disturbances
  Score sensitivity to sounds or auditory hallucinations.
• Visual disturbances
  Score visual sensitivity or visual hallucinations.
• Headache or fullness in head
  Score headache severity or head pressure.
• Orientation and clouding of sensorium
  Score orientation to person, place, time, and situation.
• Total CIWA-Ar score entered
  Enter the summed CIWA-Ar score from all 10 items.

Clinical Interpretation and Medication Response

• Withdrawal severity category documented
  Record the clinical interpretation of the total CIWA-Ar score per facility protocol.
• Medication administered per protocol
  Document whether medication was given based on the CIWA-Ar score and standing order or protocol.
• Medication details recorded
  Record medication name, dose, route, and time administered if applicable.
• Provider notified for concerning findings
  Confirm escalation to the provider for severe symptoms, worsening score, or abnormal findings requiring review.

Repeat Assessment, Safety, and Disposition

• Repeat assessment interval scheduled
  Document the next CIWA-Ar reassessment time or interval per protocol.
• Safety precautions in place
  Select applicable precautions implemented for the patient.
• Inspector signature completed
  Signature of the clinician completing the assessment.