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Run: CIWA-Ar Alcohol Withdrawal Assessment Log

Track CIWA-Ar alcohol withdrawal assessments, score each symptom consistently, and document medication response and escalation at protocol intervals. Use it ...

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Assessment Context and Timing

Assessment date and time recorded critical (required)

Assessment type identified critical (required)

Protocol interval met critical (required)

Confirm the reassessment was completed at the ordered CIWA-Ar protocol interval or sooner if clinically indicated.

Yes No N/A

Patient able to participate in assessment critical (required)

Patient is awake enough and able to answer questions or cooperate with observation-based scoring.

Yes No N/A

Last alcohol use documented

Concurrent sedating medication or confounding factor noted

Document factors that may affect interpretation of CIWA-Ar findings, such as recent benzodiazepine administration, other sedatives, delirium, or communication barriers.

Yes No N/A

Note (optional)

CIWA-Ar Item Scoring

Nausea and vomiting score critical (required)

Note (optional)

Tremor score critical (required)

Note (optional)

Paroxysmal sweats score critical (required)

Note (optional)

Anxiety score critical (required)

Note (optional)

Agitation score critical (required)

Note (optional)

Tactile disturbances score critical (required)

Note (optional)

Auditory disturbances score critical (required)

Note (optional)

Visual disturbances score critical (required)

Note (optional)

Headache and fullness in head score critical (required)

Note (optional)

Orientation and clouding of sensorium score critical (required)

Note (optional)

Total Score and Clinical Interpretation

Total CIWA-Ar score critical (required)

Severity category documented critical (required)

Protocol action based on score documented critical (required)

Document whether the score triggered continued observation, medication administration, provider notification, or higher level of care.

Yes No N/A

Provider notified for concerning findings

Use when score, symptoms, or mental status indicate need for escalation per protocol.

Yes No N/A

Medication Response and Escalation

Medication administered per protocol critical (required)

Yes No N/A

Medication name and dose critical (required)

Clinical response documented critical (required)

Record whether symptoms improved, remained unchanged, or worsened after intervention.

Note (optional)

Repeat CIWA-Ar reassessment scheduled or completed critical (required)

Document the next reassessment time or confirm the post-medication reassessment was completed.

Escalation actions documented critical (required)

Record actions such as provider notification, transfer to higher level of care, increased monitoring, seizure precautions, or safety observation.

Note (optional)

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