Patient presents with altered mental status (AMS), demonstrating a clinically significant change from baseline cognitive function.  Assessment reveals [Specify onset: acute, subacute, gradual] changes in [Specify domains affected: level of consciousness, attention, orientation, memory, language, executive function, perception, thought content, thought process, insight, judgment].  Possible etiologies considered include, but are not limited to, delirium, dementia, metabolic encephalopathy, substance intoxication, substance withdrawal, medication side effects, infection, cerebrovascular accident (CVA), traumatic brain injury (TBI), and psychiatric conditions.  Patient exhibits [Describe specific symptoms observed e.g., disorientation to time and place, confusion, agitation, lethargy, hallucinations, delusions].  Neurological examination reveals [Document findings e.g., intact cranial nerves, normal motor strength, presence of tremors or asterixis].  Current medications include [List all current medications].  Medical history significant for [List pertinent medical history e.g., hypertension, diabetes, previous stroke].  Family history includes [Note relevant family history e.g., dementia, psychiatric illness].  Diagnostic workup may include [List planned or completed tests e.g., complete blood count (CBC), basic metabolic panel (BMP), urinalysis, blood cultures, toxicology screen, neuroimaging].  Differential diagnosis includes [List potential diagnoses being considered].  Initial treatment plan includes [Describe interventions initiated e.g., monitoring vital signs, ensuring patient safety, addressing underlying medical conditions, supportive care].  Patient's mental status will be closely monitored, and further evaluation and treatment will be based on ongoing assessment and diagnostic results.  The patient's capacity for decision-making is [Specify e.g., intact, impaired] at this time.  Family or caregiver involvement is [Describe level of involvement e.g., present and providing collateral information, contacted by phone].  Continued reassessment and documentation of mental status changes are crucial for appropriate management and medical decision-making.