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Run: CIWA-Ar Alcohol Withdrawal Assessment Log

Use this CIWA-Ar Alcohol Withdrawal Assessment Log to document the 10-item score, repeat checks, medication response, and escalation decisions at protocol in...

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Assessment Context and Timing

Assessment type documented critical (required)

Identify whether this is an initial CIWA-Ar assessment or a repeat assessment.

Note (optional)

Assessment date and time recorded critical (required)

Document the exact date and time the CIWA-Ar was completed.

Protocol interval met for repeat assessment critical (required)

Confirm the reassessment occurred at the ordered protocol interval.

Yes No N/A

Patient identity verified critical (required)

Confirm patient identity using two identifiers per facility policy.

Yes No N/A

Assessment conditions appropriate

Patient was awake enough to participate and assessment was completed in a suitable setting with minimal interruption.

Yes No N/A

CIWA-Ar Item Scoring

Nausea and vomiting critical (required)

Score severity of nausea and vomiting.

Tremor critical (required)

Score visible tremor with arms extended.

Paroxysmal sweats critical (required)

Score sweating severity observed or reported.

Anxiety critical (required)

Score anxiety level reported by the patient and observed by staff.

Agitation critical (required)

Score restlessness and agitation.

Tactile disturbances critical (required)

Score sensations such as itching, pins and needles, burning, or formication.

Auditory disturbances critical (required)

Score sensitivity to sounds or auditory hallucinations.

Visual disturbances critical (required)

Score visual sensitivity or visual hallucinations.

Headache or fullness in head critical (required)

Score headache severity or head pressure.

Orientation and clouding of sensorium critical (required)

Score orientation to person, place, time, and situation.

Total CIWA-Ar score entered critical (required)

Enter the summed CIWA-Ar score from all 10 items.

Clinical Interpretation and Medication Response

Withdrawal severity category documented critical (required)

Record the clinical interpretation of the total CIWA-Ar score per facility protocol.

Note (optional)

Medication administered per protocol critical (required)

Document whether medication was given based on the CIWA-Ar score and standing order or protocol.

Yes No N/A

Medication details recorded

Record medication name, dose, route, and time administered if applicable.

Provider notified for concerning findings critical (required)

Confirm escalation to the provider for severe symptoms, worsening score, or abnormal findings requiring review.

Yes No N/A

Repeat Assessment, Safety, and Disposition

Repeat assessment interval scheduled critical (required)

Document the next CIWA-Ar reassessment time or interval per protocol.

Safety precautions in place critical (required)

Select applicable precautions implemented for the patient.

Inspector signature completed critical (required)

Signature of the clinician completing the assessment.

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